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VERIFICATION OF RESTROOM FACILITY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> VEHICLE INFORMATION:' F.- <br /> Vehicle Name (DBA): ESO�MOS�S 16In4� ani t GhuC4$ kt�-Ghees <br /> Address for Vehicle: 23 4p W u5 U�a bra c <br /> Street Address ity <br /> 1) License Plate#: FSOb`k 4) Year: 2DDb <br /> 2) Vehicle Vin#- I(,fi e:,g f g24 L Ll t)4g 3 7 a. 5) Make/Model: "CLk Mct{V-'- <br /> 3) <br /> 3) State Decal#: �J 20 01 6) Color: <br /> .VEHICLE OWNER INFORMATION <br /> Name: �abr;elaaoc4ri u mat(Alucn t C&'y14% cQL)MaCk1LL(0' <br /> Address of Owner: 23 W a tot ug Wq ra c <br /> Street Address Ci <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 /> I 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 /> sanitary condition. � <br /> t\YtCJq I1,410U a" <br /> tI�ZOLIi <br /> SI nature of Vehicle O erhitor Date <br /> -RESTROOM INFORMATION- - <br /> Business Name: 5 b G4$ .r Nae k e t <br /> Owner Name: Soanjct Q;c10 <br /> Site Address: 51 S Sr+ <br /> r1 Street Address cfty <br /> Phone: pc Dq ��� Jbg <br /> 1,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 Health Department inspection. <br /> /Vz' � q-1 -)- zo zy <br /> Signature Business owner/Operator Date <br /> EHD 16-017 6 of 6 MFPU APPLICATION <br /> 7/26/2010 <br />