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VERIFICATION OF RESTROOM FACILITY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> VEHICLE INFORIV);ATION <br /> Vehicle Name(DBA): -.7a- cps 6 <br /> - -- oyol -a <br /> Address for Vehicle: G_' cL (-Kbtr VLr <br /> Strect Address c_i( — <br /> Zip <br /> 1) license Plate#: i1 TQ75HLJ _ 4) Year: d U a _ <br /> 2) Vehicle Vin#: 1.Z_9 7 E H 2_QtJP 3'JSth /Model: <br /> i <br /> 3) State Decal #: 6) Color: <br /> VEHICLE OWNER INFORMATION <br /> Name: <br /> Address of Owner; <br /> street Address city zip <br /> Mobile food facilities shall be operated within 200 feet of approved and readily available toilet and hand <br /> washing facilities. This is to ensure restroom facilities are available to employees whenever the mobile <br /> food facility is stopped to conduct business. CalCode Section 114315. <br /> I have access to the restroom facilities at the following business during my business hours and I am <br /> parked less than 200 feet away from the restroom facilities. I will be responsible for maintaining the <br /> restroom in a clean and sanitary condition. <br /> - 4Qnea/- <br /> signature of Nettie: e Oet'ator Datc <br /> RTROOM YNFORMATION + .c* lea <br /> ES <br /> Business Name: <br /> Owner Name: <br /> WAY—)�V <br /> cc <br /> Site Address: �3�� 3 a J�1.1-�- <br /> Stree Address city Zip <br /> Phone: <br /> I, the business owner/operator,can and will provide the necessary restroom facilities for the operators of <br /> the above-mentioned vehicle at my business and I understand that the restroom facilities are subject to <br /> Environmental Health Department inspection. <br /> i <br /> S ature Business wnel/ or Date <br /> lit-ID 16-017 Page 6 of 6 MFPU APPLICATION <br /> 8/4/2006 <br /> s <br />