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X7-1 <br /> VERIFICATION OF RESTROOM FACILITY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> VEHICLE INFORMATION <br /> Vehicle Name (DBA): , ' <,-') iL/L!�- _/ <br /> Address for Vehicle: r, / -J' <br /> Street Address city <br /> 1) License Plate#: 4) Year: a 0 / <br /> 2) Vehicle Vin#: _ -._� 5) Make/Model: <br /> 3) State Decal #: 6) Color: c" <br /> VEHICLE OWNER INFORMATION <br /> Name: --o <br /> Addressof wner: -7 <br /> Street Address city <br /> Mobile food facilities shall be operated within 200 feet of approved and readily available toilet and hand washir <br /> facilities. This is to ensure restroom facilities are available to employees whenever the mobile food facility <br /> stopped to conduct business(CalCode section 114315). <br /> 1 have access to the restroom facilities at the following businegs during my business hours and I am parked le! <br /> than 200 feet away from the restroom facilities. I will be responsible for maintaining the restroom in a clean ar <br /> sanitary conditioit, <br /> S. nature of 6 r :' Date <br /> rBusiness Name ,d <";LS t4-1 c <br /> ;O r9er Name /� F f /✓ ///F LSD _ _ <br /> eAddress�-� iLL1� jL �YQC' Ca Ci r,� <br /> etre f�r:d� cl <br /> Phone. — <br /> I the business"byyneyppe ,;i'0g AIMPO*ff ?e i t _:' Str-om facilities for the operators of the <br /> above-mentioned vehicle a gad I u'r', >$ -' =--oom facilities are subject to <br /> Environmental Healfh Departmeirn$ Lx; <br /> S --at e Bus -ess owner/Operator _e <br />