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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):\li:cLA. L,1„, ,p i „, I' m i. 14 co u i ; 0 ri de_ -Ty 1111/4 txk <br />Address for Vehicle:,p,... CA Qs og- ZrdcIK-Ord U-90-1 _-1 \fe•-r- 10 oinKi -R <br />Street Addrets City <br />License Plate #: (=Ng:S-1 vl 4) Year: <br />Vehicle Vin #: -.16(4(.1364s 1 cis 61-f 5) Make/Model: (1..AgViDi&-/' SiAPCMcio <br />State Decal #: 6) Color: <br />VEtiKopF NgkINE0FOrigaN, _ :,1", . <br />• e. _ Name: V <br />Address of Owner: ‘2._)----5—s-wc,..y Coier100(41 Ki CAr- <br />Street Address City <br />MobileMobile 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 />I 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 />Signature of of Vehicle Operator Date <br />REgYliotlillIVORMS0 ' '-•- ,, <br />.. . <br />, . 4. <br />Business Name: f3is /Boy mei (t<e....„4-sI <br />.3.--417,\&.: . <br />Owner Name: <br />Site Address: 2224,c j oe..- 0 A,/ _,..„4,..,_, &-isc._ & - ; , , / 0 Ai cA. s--3 2, 0 ( <br />Street Address City <br />Phone:' 1) S 5s_ <br />I, the the business owner/operator, can and will provide the necessary restroom facilities for the operators of the <br />above-mentio vehicle at my business and I understand that the restroom facilities are subject to <br />Environment Department inspection. <br />i <br />/ <br />Signature Busine s owner/Operator Date <br />EHD 16-017 6 of 6 <br />MFPU APPLICATION <br />7/28/2010