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VERIFICATION OF RESTROOM FACILITY <br />Please provide all information requested. An incomplete application may delay approval. <br />IVEHICLE INFORMATION <br />Vehicle Name (DBA): ej J !j(G 1 li 1 {-\) '%ei L4 <br />Address for Vehicle: Z j It S . +yl,- t-Utterl-o CA 1 �I <br />Street Address City <br />4SS LA -1 89 <br />1) License Plate #: 4) Year: 201 G1 <br />2) Vehicle Vin #: LJC9 HV I S ;z_u K ML-1020f� Make/Model: <Z-1 G G -r <br />3) State Decal #: 6) Color: <br />)VEHICLE OWNER INFORMATION_ <br />Name: — <br />Address of Owner: 5 I35 c r e Sar, Pablo <br />Street Aress City <br />dd <br />Mobile food facilities shall be operated 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 business (CalCode section 114315). <br />1 have access to the restroom facilities at the following business during my business hours and I am parked less <br />than 200 feet away from the restroom facilities. I will be responsible for maintaining the restroom in a clean and <br />sanita condition. <br />�© Se �OiKc�� <br />Si nature of Vehicle O erator Date <br />(RESTROOM INFORMATION _ <br />Business Name: IN *v' <br />pr <br />Owner Name: W-- 55 <br />Site Address: } (b(�7j7� LL L/- T <br />Street Address City <br />Phone: (-z_00b Z5q -5q0 <br />I, the business owner/operator, 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 />Environmental He th Department inspection. <br />Signature Business o er/Operator Date <br />EHD 16-017 6 of 6 MFPU APPLICATION .. <br />7/28/2010 <br />