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VERIFIC16TION OF RESTROOM EACILIT Y <br /> ase provide all information request <br /> 4 2;: RR C'si ll:_ Z+�T,'m'"'J' e�� �s '-4^ t• " 4'T--f'�+ W w`YCl^—' w � - <br /> VE^H[��'E�TI�NEO '.:€`Ti 001 ��x,��',�r` `�'3'R.: `.lr.�a�','�'r';�e �����:c�d�y�'�"`"��'��' •;� ',C �,i <br /> Vehicle Name (DBA): '1 <br /> Address for Vehicle: S � 09t4 A ST <br /> Street Address City Zip <br /> 1) License Plate#: RMWA1 4) Year: lq� <br /> 2) Vehicle Vin#: I(a V,?b& Jq 33W0)6 Make/Model: . <br /> 3) State Decal #: 6) Color: _ ar <br /> �x�ae € r�+'3.i�,...� st r -st+�.s,.— 1 i^ —rr, 'xw`•.^ r "'ak t f° �3 - 7 ,^ <br /> VEHICI- -M I N�R'INF,OR1VIAeTI©N£v a C � `, rr i#t ' su <br /> Name: 94.TU • %QAY.QNF1 9 1x483 <br /> Address of Owner: hip-0-AV fl O�J <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 /> i f <br /> r r <br /> Signature of Vehicleerator ate <br /> ROO ©M INF,,ORM�ATi011T�'r� ct :1....��n ��1�tar v 2 �` '•s�f'e=s" +` .s''"*r,�"`� �F��.�`�°'` ���: <br /> Business Name: <br /> Owner Name: <br /> Site Address: �S e �H� T. 5 O <br /> Street Address City Zip <br /> Phone: (21x{) f f <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 /> Environ ental 1th Department inspection. <br /> u <br /> Sign re Business owner/Operator Date <br /> VED <br /> OCT 27 2016 <br /> EHD 16-013 Page 9 of 9 MFF APPLICATION <br /> 8/17/2007 <br />