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F 7777!7777 <br /> VERIFICA,.TION OF RESTROOM FACILITY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> Vehicle wsx� n, <br /> Name (DBA): 'rQ C 5 n <br /> Address for Vehicle: Z b <br /> 5trret Address City 7Ap <br /> 1) License Plate #: }` 4) Year: -201q <br /> 2) Vehicle Vin #: <br /> ) Make/Model: 2A q MX�C� <br /> 3) State Decal #: G) Color: <br /> -45Z <br /> Ti BMUC <br /> Iam e: 1 <br /> ddress of Owner. 't <br /> Street Address City CIS 2 7Jp <br /> obile food facilities shall be operated within 200 feet of approved and readily available toilet and hand <br /> asking facilities. This is to ensure restroom facilities are available to employees whenever the mobile <br /> od facility is stopped to conduct business. CalCode Section 1.14315. <br /> have access to the restroom facilities at the following business during my business hours and I am <br /> rked less than 200 feet away from the restroom facilities. I will be responsible for maintaining the <br /> froom in a clean and sanitary condition. <br /> 27-76 <br /> Patu�e of Vehicle O erator Date <br /> QOs Name: Lc.r C7'<-' V 1 LLQ U'-/� tDi2.� <br /> er Name: 1' 4 <br /> Address: 'LL/'r� 440 /�-t�trrzl�"t7 9522 <br /> (,-Ivq ) Street Address City Zip <br /> business owner/operator, can and will provide the necessary restroom facilities for the operators of <br /> Bove-mentioned vehicle at my business and I understand that the restroom facilities are subject to <br /> ronmental Health Department inspection. <br /> 0111q12,0 D <br /> rurceffusincess owner/Operator Date <br />