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VFRIFIC. ' BION OF RESTROOM F kCILIT <br /> I.stse provide all information requestet.. <br /> VEHICLE INFORNtATION <br /> Vehicle Name(DBA): h 0\ <br /> Address for Vehicle: - -- --- -- - - ---- - -- <br /> Street Address City Zip <br /> 1) License Plate#: J 3 LO'3 4) Year: <br /> 2) Vehicle Vin#: <br /> 3) State Decal#: 6) Color: v <br /> VEHICLE OWNER INFORMATION -- <br /> Name: 1 a • L-0c)-ez <br /> Address of Owner: <br /> Lonj <br /> Street Address Cit} 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 Vel cle O erator Date <br /> RESTROOM INFORMATION Room <br /> Owner <br /> . <br /> Business Name: ��-yy� y <br /> Owner Name: 5 <br /> Site Address: ! jL <br /> StreeY Addres City% Zip <br /> Phone: " . <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 /> Envir nmental Healt Department inspection. /^J <br /> Signature Busines o er/Operator Date <br /> RECEIVED <br /> fc <br /> 20 i9 <br /> e,N'JIRONMENTAL HEALTH <br /> PERMITISERVICES <br /> EHD 16-013 Page 9 of 9 MFF APPLICATION <br /> 8/17/2007 <br /> �-0�23 0 2 <br />