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VERIFICATION OF RESTROOM FACILITY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> NEHI,CLEINFQ,RMATION -: � Ir,•_, <br /> Vehicle Name (DBA): '15055 <br /> Address for Vehicle: 7 <br /> Street Address City - <br /> 1) License Plate * 4) Year: <br /> 2) Vehicle Vin $6 X/b5LM 99,;?•35 5) Make/Model: <br /> 3) State Decal #: 6) Color: <br /> F <br /> VEHICLE OWNER INFORMATION <br /> Name: 2lC U �r`--CJ�v�GL <br /> Address of Owner: '2_a%O p•;.1���� C. �GLQ� <br /> Street Address City <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 parkdd 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 /> -_ — <br /> ------------------------------ ----- ---------- <br /> Signature of Vehicle Operator Date <br /> RESTROOM INFORMATION <br /> Business Name: <br /> Owner Name: <br /> Site Address: 51L4 w N\L e rC> ' o <br /> Street Address C ty ' <br /> Phone: C> <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 1 understand that the restroom facilities are subject to <br /> Environmental Health Department inspection. <br /> Signatuririess owner/Operator Date <br /> EHD 16-017 6 of 6 MFPU APPLICATION <br /> 7/28/2010 <br />