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VERIFIWION OF RESTROOM kCILITY <br /> a . se provide all information eVW <br /> VEHICLE INFORMATION <br /> Vehicle Name (DBA): F(,(CtUY ICL <br /> Address for Vehicle: l� � 'CIA - (2 <br /> Street Address City Zip <br /> 1) License Plate#: 9 �}, 4) Year: ny'Ll <br /> 2) Vehicle Vin#: U�, 2j2�'C� 3 �� ) Make/Model: \J (� <br /> 3) State Decal#: 8 6) Color: <br /> VEHICLE bWNER+INFORMATION <br /> Name: v.k,` mer <br /> Address of Owner: kC C Z 2 <br /> Street AddrtA 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 /> l ,(,- 17J 11-10 <br /> Signature of Vehicle Op for Date <br /> RESTROOM INFORMATION <br /> Business Name: ti <br /> Owner Name: �' i <br /> Site Address: q7 5 Ci <j <br /> Street Address City Zip <br /> Phone: (707) a <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 /> 7Env�;ir7,,"f1a-_1_Malth Department inspection. <br /> Si ature Business owner/Operator Date <br /> DEE G 12 2018 pry 9 Z 2013 <br /> r-NVIRONMENTAL HEALTH "viROINIMENTAL HEALTH <br /> PERMIT/SERVICES ''FRMIT/SERVICES <br /> EHD 16-013 Page 9 of 9 MFF APPLICATION <br /> 8/17/2007 <br />