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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) : f v � - ` <br /> VIA <br /> " <br /> Address for Vehicle : c'� ��1 ' L ' �' 2v� c` <br /> Street Address City <br /> 1 License Plate # : J 4 ) Year : eel <br /> II <br /> 2 ) <br /> 2 ) Vehicle Vin # : CO 5 C � z� ) Make / Model : <br /> 3 ) State Decal # : 7 6 ) Color : — <br /> cl <br /> VEHICLE OWNER INFORMATION <br /> Name : ` ` =� <br /> ,� C <br /> Address of Owner : S _ C> cl �= CJ , � ri <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 /> V <br /> than 200 feet away from the restroom facilities . I will be responsible for maintaining the restroom in a clean and <br /> sanitary condition . g <br /> Si nature of Veh ' e Operator <br /> Date <br /> RESTROOM INFORMATION <br /> co fc <br /> Business Name : <br /> Owner Name : <br /> 4000 <br /> Site Address : �-, 3 �pkr �"�� <br /> Street Address City <br /> Phone : <br /> 1 , the business owner/operator , can and will provide the necessary <br /> hat the restroom facilities ities ties arethe <br /> subject to <br /> operators <br /> of the <br /> above - mentioned vehicle at my business and I understand <br /> Environmental Health pa me ' nspection . <br /> I - 0 <br /> ture Busine o r/ perator Date <br />