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VERIFICATION OF RESTROOM FACILITY <br /> Mwnw V.,)*)* rs .�",rWj,4n tpgyaaUd An delay approval. <br /> Affoaft'to V4000 a A•r�i it'd 111J - <br /> �, /- 6/ <br /> t► ut+rrietslala• <br /> ]FOAM 4)A Year <br /> 2) Veftela Vin e / N n��1�' l?51Make/Model. (SNE 2& f9- �� ✓1 <br /> 3) SM@ CWAM• 6) Col <br /> �MIIQ I�.LLKZ'YJr�.� UCr• I r <br /> Aan r.as c�t;i,, rl�rr lh 531n <br /> Mobite rood l adws shall be operated wdlun 200 feet of approved and readily available toilet and hand washing <br /> fatrtaa% This is 10 enswe restroom facilities are available to employees whenever the mobile food facility is <br /> %tapped to conduct business fcalcode section 114315). <br /> 1 have accass to the restroom facilities at the following business during my business hours and I am parked less <br /> than 200 foal ay from the restroom facilities. I will be responsible for maintaining the restroom In a clean and <br /> i f tlll}on, <br /> S&Run <br /> Ob' as -aG� <br /> 0 of Vehicle Ooerstor Date <br /> Business Name: r,S 62c <br /> Owner Name: /5: P C O <br /> Site Address nC l <br /> atreel rens c <br /> Phone <br /> I,the business owner/operator,can and will provide the necessary restroom facilities for the operators of the <br /> above-mentioned ve Icle at my business and I understand that the restroom facilities are subject to <br /> Environmental Htali 0�gertment inspection. <br /> CJ <br /> titi �C) <br /> 6 <br /> y <br /> Signature Business owner/Open or Date S <br /> END 1"17 W6 6 MFPU APPLICATION <br /> 7292010 <br />