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VERIFICATION OF RESTROOM FACILITY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> VEHICLE f\TOI;L%,1,M0 V <br /> Vehicle Name (DBA): CIla <br /> Address for Vehicle: ( S <br /> a i Esc �. {�cok �Zas <br /> Street Address <br /> City Zip <br /> 1) License Plate 4) l - e?7 <br /> 2) Vehicle Vin#: L Ll 0�/�/� C� ake7lVlodeL <br /> 1-o <br /> 3) State Decal #: b ()4 q 6) Color: / <br /> VEMCLE OWNER NIVFORMATION <br /> Name: 3 760 <br /> Address of Owner: 68 <br /> r`` of v+to CGr <br /> ' Strcet Address City <br /> 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 /> 6. STROOM <br /> room in clean and sanitary condition. <br /> re of Vehicle Operator Date <br /> NFORINIATION <br /> Business Name: o f .f�64 � <br /> Owner Name: Di G� i� <br /> e <br /> Site Address: 1 2� -7 Z <br /> Street Address <br /> Phone: Za qQ 3 l — 3/ S City Zip{ <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 Busl e o ne / pe ator ate w <br /> EPage 6 of 6 <br /> HD 16-017 <br /> MFPU APPLICATION <br /> 8/4/2006 <br />