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VERIFICATION OF RESTROOM FACILITY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> � � ­1120c <br /> 4 i � <br /> VEHICLE INFORMATION <br /> Vehicle Name (DBA): c, ���f� ✓�G <br /> Address for Vehicle: ���j_'� _ / ; <br /> Street Address City <br /> 1) License Plate #: C_, 9 Y'1 J 1 _ 4) Year: <br /> 2) Vehicle Vin #: I(,W413 HE-3 �5q 5) Make/Model: <br /> 3) State Decal #: 6) Color: <br /> VEHICLE OWN R INFORMATION <br /> Name: _ f ' l N - - - <br /> Address of Owner: �`,�c�s ( 1 T I ��1-„-_ - SCK N <br /> Street Address City <br /> Mobile food facilities shall be operated within 200 feet of approved and readily available toilet and hand washing <br /> facilities. This is to ensure restroom facilities are available to employees whenever the mobile food facility is <br /> stopped to conduct business (CalCode section 114315). <br /> 1 have access to the restroom facilities at the following business during my business hours and I am parked less <br /> than 200 feet away from the restroom facilities. I will be responsible for maintaining the restroom in a clean and <br /> sanitary,condition. / <br /> Si nature of ehicle O erator r,11 Date <br /> RESTROOM INFORMATION <br /> Business Name: M0'-r Icy <br /> Owner Name: <br /> Site Address: 007 �Z f� l}L� 06,0(400 —�' `' , <br /> Street Address City <br /> Phone: � 2 7 f 3 `� _ <br /> I,the business owner/operator, can and will provide the necessary restroom facilities for the operators of the <br /> above-mentioned vehicle at my business and I understand that the restroom facilities are subject to <br /> Environm tal Health Department inspection. <br /> /I V'J' <br /> Signature Business owner/Operator Date <br /> r�. <br /> t <br /> EHD 16-017 W6 6 Y` MFPU APPLICATION <br /> 7/28/2010Ali <br /> s s� <br /> . . <br />