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VERIFICATION OF RESTROOM FACILITY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> ,VEHICLE INFORMATION. <br /> Vehicle Name (DBA): <br /> Address for Vehicle: <br /> Street Address City Zip <br /> 1) License Plate#: R 6 992,11 4) Year: , <br /> 2) Vehicle Vin#: (��3e 7.��32(�Q 5) Make/Model: <br /> 3) State Decal #: 6) Color: <br /> VEHICLE OWNER INFORMATION <br /> Name: in MCI ldonajo <br /> Address of Owned <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 /> Signatu e o Vehicle O erator Date <br /> {RESTROOMII�FORMATION <br /> Business Name: <br /> Owner Name: LfT <br /> Site Address: Tkorf)tnn -Rd . 91168 Cc <br /> Street Address City Zip <br /> Phone: nign <br /> — <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 /> �AWRO,4 , ?-10, Is, <br /> Signature Business owner/Operator Date <br /> EHD 16-017 Page 6 of 6 MFPU APPLICATION <br /> 8/4/2006 <br />