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VERIFICATION OF RESTROOM FACILITY Please provide all information requested. An incomplete application may delay approval. : VEHICLE INFORMATION: .1 Vehicle Name (DBA).--ra 6e5 6-th61' 1 (o Address for Vehicle: I -7 1-7 5, ki 0 ;a ,, 5—, chcc.1-6 h CiSt 0 3 Street Address City Zip e> ....... License Plate #: 15,52_ & s-y 2_ 4) Year: 19,1:Ss- Vehicle Vin #: I (4 B I t ps 2 riti 133 hOo ? 5) Make/Model: V _CINe. State Decal #: 6) Color: 'j2,1 ACK . 2, EIH—CL4-10.CY-NE— ii. Oiniiiiii6K1..W. .77;251.:r. t r.'" 7"--,,r,_':: ' ''''',Z.: h ;!"'n-rlts*."-- -5T-T A Name: -6,8m 01 /41.-01,0 2--)a 4 1 0... Address of Owner:3 91 ci 1 9 • prnbA11 Lana siocz-V-e r 13-74 Street Address City Zip Mobile food facilities shall be operated within 200 feet of approved and readily available toilet and hand washing facilities. This is to ensure restroom facilities are available to employees whenever the mobile food facility is stopped to conduct business. CalCode Section 114315. I have access to the restroom facilities at the following business during my business hours and I am parked less than 200 feet awa from the restroom facilities. I will be responsible for maintaining the testroo a clean a.. anitary c dition. , Signature eh cle bperator Date .RESTROOM FORMATION( _ ,_, _ _ — _ _ — - .1- — — - I Business Name: Pe( cecbov, Aurh, Pckt -ri € 1 ,A c °wile'. Name: 'ICI I 0•2 g CtIrYll r CZ Site Address: ck 2-S m . Wt I on uoctsi 3\--0 C-1-b\r"\ 0 fl- 15205 Street Address City Zip Phone: 209 c19‘-90/J I, the business owner/operator, can and will provide the necessary restroom facilities for the operators of the above-mentioned vehicle at my business and I understand that the restroom facilities are subject to Environmental Health Department inspection. Business owner/Operator Date EHD 16-017 Page 6 of 6 MFPU APPLICATION 8/4/2006