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VERIFICATION OF RESTROOM FACILITY <br /> Please provide all information requested_ An incomplete application may delay approval. <br /> VEHICLE INFORMATION <br /> Vehicle Name (DBA): E & B 'S BBQ SMOKE SHACK <br /> Address for Vehicle: 663 SUTHERLAND DR. STOCKTON,CA 95210 <br /> Street Address city <br /> 1) License Plate#: 4NR8746 4) Year: 0000 YR 1 ST SOLD <br /> 2) Vehicle Vin#: OR54538 5) Make/Model: SPCNSNAR./TRAILER <br /> 3) State Decal#-. 27027 6) Color: BLACK&WHITE <br /> VEHICLE OWNER INFORMATION <br /> Name: Edward Lee/Vernetta Holland-Lee <br /> Address of Owner: 663 Sutherland dr. Stockton, Ca.95210 <br /> -- - — Street Address city <br /> Mobile food facilities shall be operated within 200 feet of approved and readily available toilet and hand washing <br /> facilities. This is to ensure restroom facilities are available to employees whenever the mobile food facility is <br /> stopped to conduct business(CalCode section 114315). <br /> 1 have access to the restroom facilities at the following business during my business hours and I am parked less <br /> than 200 feet away from the restroom facilities. I will be responsible for maintaining the restroom in a clean and <br /> sanitary condition. <br /> 7 <br /> Si nature of Vehicle Operator Date <br /> RESTROOM INFORMATION <br /> Business Name: L'� /`)v ? �1 <br /> Owner Name: <br /> Site Address: <br /> � Street dress city <br /> Phone: <br /> 1,the business ownerloperator,can and will provide the necessary restroom facilities for the operators of the <br /> above-mentioned vehicle at my business and I understand that the restroom facilities are subject to <br /> Environmental Health 96pa ent inspection. <br /> C 4 <br /> Signature Business owner/Operator Dat <br /> FHD 16-017 6 of 6 MFPU APPLICATION <br /> 7/28/2010 <br />