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VERIFICATION OF RESTROOM FACILITY <br /> P ease provide a information requested An incomp ete app ication may de ay approva <br /> VEWclEi,tr-OP to'Pfifl <br /> Vehicle iName(DBA)•. �j//✓C 0/J TCi}cc1 V 2�l O <br /> Address 10,Veh4Ie: 2Cioo r. 14G(dfVj!q WQy_�_ S�C� cI<9O, i� eQ . _gSZorj <br /> Sl:e,A At&.— s rAy <br /> 11 Uce,-�se ?lace-�4: y?N 2-9 3 F) 11> Yea-: 20 t <br /> 2) Vah;de\Fw,, t; ( S986)< 1 87 G M 982,0Z2+1j maVe;w:cO&, ScwT UJ 557^ <br /> 3) Sime ver..al'?: <br /> E��.f�_F+eFy�JA'pl��t7.+t'fa " . . . <br /> Name: 1-401c O /� • cSo j E CO --- -- -- --, <br /> Addrass o`: 4vorsr. "7�iZo�, 0 —LN S IAC V,Lr: . C n/ �? 5Z 1 Z <br /> islet Add�es: <br /> Mobile food facilities shalt be operated within 200 feet of approved and readily available toilet and hand washina <br /> facilities. This is to ensure restroom faaities are avallahis to e:rotoyees Whene•rer the mobite food fscil:ty is <br /> stopped to conduct business(CalCods section 114315). <br /> t have access to the restroom facilities at tt1_folicAving business during my business hours and 1 am parked less <br /> than 200 feet away from the restroom facilities. I wfitl be respansible for maintaining the restroom in a clean and <br /> sanitary con iti .11 <br /> Sianatum of Vehic4e Ctveratar Date <br /> ,RGS�' tED0t.1�2+t�G1lifwkTI'L)41 .. , <br /> Business Name: �YL �1�"' �11S. C • OKE�PI� 2IP <br /> fivmerSk--Do—new I.rIZU'lC� <br /> SileAddress 1–+da <br /> .. Vie"Add:E s Cly <br /> Phone: ( i1 �-f.S=2:1 Jac—) — — ----- – <br /> S,the business 0WnSTS0peTat0T, can and will pvcmide the.necessary resisoom fatffitiss for Lis opemlors of trre <br /> above-men}' ned ehicfe atm business and I understand that the restroom facilities are subject to <br /> Environ -., aI Heat Nasrmenl inspection. <br /> Si4.,a ur_ `usfne.9s Owrleri'Operator nate <br /> RECEIVE® <br /> PIOV 14 2016 <br /> ENVIRONMENTAL H <br /> PERMIT/SERVICES <br /> EHD 16 017 6 of 6 fv1FPU APPL CAT ON <br /> 7/28/2010 <br />