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VERIFICATION OF RESTROOM FACILITY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> Vehicle Name (DBA): ZA 60 A m <br /> Address for Vehicle: C2p 5 �A city <br /> � ztp <br /> Street ddress <br /> 4 7()71 <br /> 1) License Plate#: Year:�-�-��j ) <br /> 2) Vehicle Vin#: _ 5) Make/Modul: —rPAl[-o�-K <br /> 3) State Decal #: 6) Color: Per-> <br /> N'rllic-IX OWNERIjNTrORN1EkTlON <br /> r'AWyr, <br /> A�l��cs of O��nei �2o Sff115Z.4 <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. o- business hours and I am <br /> I have access to the restroom facilities at the following business during, m y <br /> parked less than 200 feet away from the restroom facilities. I will be responsible for maintaining the <br /> restroom a clean and sanitary condition. <br /> Sit 'ehicle Operator Dile <br /> m <br /> RESTROovlINFORIIAPI05 <br /> Business Name: - <br /> Owner Name: <br /> NI A6�t£ P_ 7 Ti�� Q5316 <br /> Site Address: 2-q 6 City Zip <br /> Street Address <br /> Phone: -ZC)9634 — 8`l-15 <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 /> P zstl� ru 'L� <br /> Sign re usu�owner/Operator Date <br /> P(. o S4-f S89 <br /> 5 <br /> .... <br /> Page 6 of 6 MFP11 APNL WA 1 h? <br />