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VERIFIC ION OF RESTROOM *CILITY <br />e provide all information requeste <br />Win r , <br />j,Ri,. <br />•.`iia.-+. v'�Q�� L.. .9 rr <br />Vehicle Name (DBA): p C, e,v- o iIno <br />Address for Vehicle: <br />Street Address City Zip <br />1) License Plate #: r'L -7 L9Cf 4) Year: q 7 cf <br />2) Vehicle Vin#: C -PL;Z]%.,3 t 5) Make/Model: <br />3) State Decal #: 6) Color: <br />VEHICLE: O R INFORMATION <br />Name: <br />Address of Owner: c, pt;i� <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 Vehicle Operator —�� Date <br />RESTROOM INFORMATION <br />Business Name: 'F, W �kA-_94 <br />Owner Name: <br />Site Address: 3 $ E . e'�k_ 11S <br />Street Address—City Zip <br />Phone: 3 y <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 />Signature Business owner/Operator Date <br />EHD 16-013 Page 9 of 9 MFF APPLICATION <br />8/17/2007 <br />