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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): ISlat�d C� e �e <br /> Address for Vehicle: 11 SGZ SDV,1crStM, (fit 4 y�v-b <br /> Street Address City <br /> 1) License Plate#: 4 4B to0g3 4) Year: -]Do(e <br /> 2) Vehicle Vin #: 41oGVrI6Z4i.MbCU463 5) Make/Model: Trc <br /> 3) State Decal #: 6) Color: blu�t'�ttzu, <br /> VEHICLE OWNER INFORMATION <br /> Name: Z► icer Islay, <br /> Address of Owner: 13 <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 /> ���L1 t /1 F I C X�(J 2_0 271 <br /> Si nature of Vehicle Operator Date <br /> RESTROOM INFORMATION <br /> Business Name: U�CICoy..e �2vr'cf <br /> Owner Name: 'RIvcX lS d o <br /> Site Address: 14D1 1�i�. tiS1aN,dS kw l-aiYtro <br /> Street Address City <br /> Phone: -zaal 9 61.M <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 /> Enp6nmental Health Department inspection. <br /> "112%(2 O2- <br /> Signature Business owner/Oper for Date <br /> EHD 16-017 6 of 6 MFPU APPLICATION <br /> 7/2812010 <br />