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VERIFICATION OF RESTROOM FACILITY <br /> Please provide all information, requested. An incomplete application may delay approval. <br /> Vehicle Name(DBA): <br /> Address for Vehicle: <br /> Street Address city Zip <br /> 1) License Plate#: C, yG2J.L 4) Year: 17 j P, <br /> 2) Vehicle Vin#: 5) Make/Model: <br /> 3) State Decal#: 6) Color: <br /> n..... <br /> RX <br /> Name: (rvnlo Mo [don n rJo <br /> Address of OwneYJ <br /> ,i M -1_�Orn6)n . OA . 9a86 <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 /> SignatWeoYVehicle'Opefator Date <br /> Business Name: _r6y-n�nr) <br /> Owner Name: )I W�LEUT My?'FOU <br /> Site Address: 2 G3 J() KI Tkorrdan Rd G <br /> Street Address city Zip <br /> Phone: 0-0gl opli <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 />