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VERIFICATION OF RESTROOM FACILITY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> VEHICLE <br /> Vehicle Name(DBA): <br /> Address for Vehicle: <br /> Street Address City Zip <br /> 1) License Plate#: 4) Year: -1-7 <br /> 2) Vehicle Vin#: 5) Make/Model: --..0- (nev V <br /> 3) State Decal#: 6) Color: <br /> Name: <br /> , -rnto Mn1donodin <br /> Address of Own6.) <br /> KInwH llorn )n . PA . 9ap�6 <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 /> Signat&� oYVehicle'Operator Date <br /> 4-7 RESTROOIVIW';'I'll ' q�;- <br /> Business Name: Tkoy-Lior) - <br /> Owner Name: �)W P�L'F—1 \.I V 9T <br /> Site Address: 2&31() KI 1-korri6y) -Rd - rLirL . TT6 C_ <br /> Street Address city Zip <br /> Phone: opil <br /> 1, 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 Business owner/Operator Date <br /> EHD 16-017 Page 6 of 6 <br /> 8/4/2006 MFPU APPLICATION <br />