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VERIFICATION OF RESTROOM FACILITY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> VEHICLE INFORMATION'. <br /> Vehicle Name (DBA): 50hhh S�Y%(\9_f end CAecc _t t huCu$ ��Ghet7 <br /> Address for Vehicle: 234D LO IrL.L� 1DOLti c <br /> Street Address ity <br /> 1) License Plate#: 1ANk1% 2S()b\4 4) Year: 2DOlo <br /> 2) Vehicle Vin#: 1lv h tr,B 122i 6Li 0 4q 3-7a 5) Make/Model: "Cl kMar Ir <br /> 3) State Decal#: -32-0 'b 6) Color: 010Lt1o2 f-Nw- o <br /> VEHICLE OWNER INFORMATION - <br /> Name: br;ela ao&ri u (ti1acl,uca t Cance,' auma6ALLt0. <br /> Address of Owner: 23 W u 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 /> kui� �I4 4mou9 <br /> Si nature of Vehicle Operkitor Date <br /> RESTROOM INFORMATIOW- - - - <br /> BusinessName: 5ke.t <br /> Owner Name: So n q %,%,r k c . <br /> Site Address: 51 rj W k kt"% S* 1`e e fi \-a c <br /> Street Address CRY <br /> Phone: R09 vo3y 9 0 $ <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 Health Department inspection. <br /> /y- �, � 1 -)- ZC)Z� <br /> Signature Business owner/Operator Date <br /> EHD 16-017 6 of 6 NFPU APPLICATION <br /> 7/26/2010 <br />