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r <br /> VERIFICATION OF RESTROOM FACILITY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> VEHICLE INFORMATION <br /> Vehicle Name (DBA): 0 S5 <br /> Address for Vehicle: LkKk U ti �' t. Y i 1 7 1 .? <br /> Street Address City <br /> 1) License Plate #: 4) Year: <br /> 2) Vehicle Vin #: !S1?S6 X I b SLM `yq 5) Make/Model: <br /> 3) State Decal #: 6) Color: j53 Az- C.� <br /> VEHICLE OWNER INFORMATION <br /> Name: 2 l ,rt o yx GL <br /> Address of Owner: .)`�%L, <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 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 /> –`JJ3 <br /> -------------------------- – ——`---z J -- <br /> Si nature of Vehicle Operator Date <br /> RESTROOM INFORMATION <br /> Business Name: \A.: n <br /> Owner Name: <br /> Site Address: Ll r e �- Jt c-ackd <br /> Street Address C <br /> Phone- C Z ZIA CJS <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 D partmentt inspection. <br /> Signature Bu$inesso ner/Operator Date <br /> EHD 16-017 6 of 6 MFPU APPLICATION <br /> 7/28/2010 <br />