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SAN JOAQUIN a.:OUNTY ENVIRONMENTAL HEALTH._CPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />Mobile Food Unit <br />FACILITY ID # <br />_Ma. b00 61(10 SERVICE REQUEST # <br />Se00(1V7- <br />OWNER / OPERATOR <br />CHECK if Cygnus Home Service, LLC. d.b.a. Schwan 's Home Service BILUNG ADDRESS <br />FACILITY NAME Schwan 's Home Service Truck 519037 <br />SITE ADDRESS 575 <br />Street Number Direction <br />Industrial Park Drive <br />Street Name <br />Manteca <br />City <br />95337 <br />Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />Street Number Street Name <br />Cm( STATE ZIP <br />PHONE #1 Err. <br />( 209) 824-3011 <br />APN # LAND USE APPLICATION # <br />PHONE #2 Err. <br />( 507) 537-8848 <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />Vijay Singh CHECK if BILLING ADDRESS <br />IN <br />BUSINESS NAME <br />Cygnus Home Service, LLC. d.b.a. Schwan's Home Service <br />PHONE # EXT. <br />( 209 ) 324-5861 <br />HOME or MAILING ADDRESS P.O. Box 127 <br />FAX # <br />( 507) 537-5183 <br />CITY Marshall STATE MN ZIP 56258-0127 <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br />acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br />or activity will be billed to me or my business as identified on this form. <br />I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. <br />• APPLICANT'S SIGNATURE:7 .4201.4edif DATE: 12/5/2019 <br />PROPERTY / BUSINESS OWNER El OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT 121 <br />IfAPPLICANT is not the BILLING PARTY, proof of authorization to sign is required <br />Division Controller <br />Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the <br />above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/ ite assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at th time it is <br />provided to me or my representative. <br />It/ <br />TYPE OF SERVICE REQUESTED: Initial Inspection <br /> <br />1(2 13 <br />COMMENTS: f <br />A, 415)4Q/, eft <br />--,,,p7.41-it <br />ACCEPTED BY: EMPLOYEE #: DATE: <br />ASSIGNED TO: 63 c„AxtA rlify.... EMPLOYEE #: DATE: <br />Date Service Completed (if already compl e : SERVICE CODE: 66i PIE: /t2.3 <br />Fee Amount/54„?. 00 Amount Paid )6//c.--2 oD Payment Date <br />Payment Type ak..... Invoice # Check # // 2,3/ g Recei d By: (1/73$------ <br />SR FORM (Golden Rod) EHD 48-02-025 <br />REVISED 11/17/2003