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i <br /> VERIFICATION OF RESTROOM FACILITY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> VEHICLE INFORMATION <br /> Vehicle Name (DBA): ` k <br /> �Y ,Y\/\13 1 c � r <br /> Address for Vehicle: `2 6 SS <br /> Street Address City <br /> 1) License Plate #: S u 4) Year: <br /> 1 5 Make/Model: <br /> 2) Vehicle Vm #: � � (� lJ z� _ ) - <br /> L <br /> 3) State Decal #: S L 7 6) Color. rL�_�L}7 -- <br /> VEHICLE OWNER INFORMATION <br /> Name: --- <br /> Address of Owner: � > S (���.t-_�-C _ � � `� C --- <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 /> than 200 feet away from the restroom facilities. I will be responsible for maintaining the restroom in a clean and <br /> sanitary condition. <br /> Si nature of Veh e Operator Date <br /> RESTROOM INFORMATION <br /> Business Name: <br /> - �— <br /> Owner Name: <br /> Site Address: �3�0 s �- - n-} - -- --= 'City <br /> Street Address l <br /> Phone: a� l C — <br /> I, the business owner/operator, can and will provide the necessary restroom facilities for the operators of the <br /> above-mentioned vehicle at my business and I understand that the restroom facilities are subject to <br /> Environmental Health a me .nspection. <br /> ture Busine o r/ perator Date <br /> r <br />