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VERIFICATION OF RESTROOM FACILITY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> VEHICLE INFORMATION_ -- <br /> Vehicle Name (DBA): S � es O_�o <br /> Address for Vehicle: 2g71S <br /> Street Address city <br /> 1) <br /> 1) License Plate#: f 1�SU� O 56 q4))4 Year: <br /> 2) Vehicle Vin#: �-` I�q U 2�XKS�3) Make/Model: �Q K Tr al ltr <br /> 3) State Decal#: 6) Color: P( <br /> VEHICLE OWNER INFORMATION <br /> Name: <br /> Address of Owner: g �a�KLA <br /> Street Address City <br /> Mobile food facilities shall be operatey 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 busi=facilities <br /> a section 114315). <br /> 1 have access to the rest at the following business during my business hours and I am parked less <br /> than 200 feet away from i e restroom facilities. I will be responsible for maintaining the restroom in a clean and <br /> sanitary condition. <br /> Roso G Zl (Z2_ -7- Q- 2020 <br /> Signature of Vehicle Operator Date <br /> RESTROOM IWIDR_ AT_IO.N --- <br /> Business Name: MSew? <br /> Owner Name: JA40n t <br /> Site Address: /S/DO <br /> Street Address City <br /> .Phone: 09-98Z-S2S�8 <br /> I,the business ownerloperator, 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 /> Envir mental Heal h Department inspection. <br /> ature Business owner/Operat Date <br /> EHD 16-017 6 0f 6 MFPU APPLICATION <br /> 7282010 <br />