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VERIFIC " TION OF RESTROOM ""ACILITY <br /> .ease provide all information request,._. <br /> t O <br /> IMMM! !A Y i.'.Ei V. 2si 1A <br /> Vehicle Name (DBA): bu 5 <br /> Address for Vehicle: 1d 1 " _ t Q L(n) <br /> Street Address V City Zip <br /> 1) License Plate#: -19 1 1 01U 4) Year: EA9 z{ <br /> 2) Vehicle Vin#: 1 Cz�T P32K�I(4,a3cty g5) Make/Model: C' Nb r <br /> 3) State Decal #: C-N 6) Color: <br /> VEHICLE OVVNIi;R INFORMATION + r <br /> Name: <br /> Address of Owner: <br /> Street Address City Zip <br /> Mobile food facilities shall be operated within 200 feet of approved and readily available toilet and hand <br /> washing facilities. This is to ensure restroom facilities are available to employees whenever the mobile <br /> food facility is stopped to conduct business (CalCode section 114315). <br /> I have access to the restroom facilities at the following business during my business hours and I am <br /> parked less than 200 feet away from the restroom facilities. I will be responsible for maintaining the <br /> restroom in a clean and sanitary condition. <br /> Signature of Veh e Operator Date <br /> t <br /> zRESTROOM INtORAIIATION ,. <br /> Business Name: C�TSS f C' (,'U 11 <br /> Owner Name: f, ( pwG'S` acw <br /> Site Address: 7­2 GI "(/\�, I(,o C K 'Vat 611 , IC 5 <br /> Street Address City Zip <br /> Phone: (2ir'f) ��� � 13 U <br /> I, the business owner/operator, can and will provide the necessary restroom facilities for the operators of <br /> the above-mentioned vehicle at my business and I understand that the restroom facilities are subject to <br /> Environmental Health Department inspection. <br /> aL\i 151zoIC1 <br /> Signature Business owner/Operator Date <br /> L DECEIVE <br /> 't� R 2 >, 21ilu <br /> ENVIRONMENTAL HEALTH <br /> PERPA1T/SERV10ES <br /> EHD I6-013 Page 9 of 9 MFF APPLICATION <br /> 8/17/2007 <br />