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SAN JOAQUI- —'OUNTY ENVIRONMENTAL HEALTH_,iPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICEREQUEST# <br /> Mobile Food Unit go 1���✓ �� uu4 '��� <br /> OWNER/OPERATOR <br /> Cygnus Home Service, LLC. d.b.a. Schwan's Home Service <br /> CHECKIfBILLINGADDRESS❑ <br /> FACILITY NAME Schwan's Home Service Truck 519037 <br /> SITEADDRESS 575 Industrial Park Drive <br /> Manteca 95337 <br /> Street Number I Direction I Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 Ex-r. APN# LAND USE APPLICATION# <br /> ( 209) 824-3011 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( 507 ) 537-8848 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Vijay Singh CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> Cygnus Home Service, LLC. d.b.a. Schwan's Home Service (209 ) 324-5861 <br /> HOME or MAILING ADDRESS FAX# <br /> P.O. Box 127 ( 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: � 'r �• DATE: 12/5/2019 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® Division ContYoller <br /> If APPLICANT is not the BILLING PARTY'proof of authorization to sign is required 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 thrtime it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: Initial Inspection <br /> COMMENTS: <br /> yc�FT�R N�,ti,�o®l.9 <br /> OFpgRNTg4 <br /> MFHT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: o� EMPLOYEE#: DATE: <br /> Date Service Completed (if already comp) a l: SERVICE CODE: l PIE: <br /> Fee Amount /5d.no Amount Paid ���, �� Payment Date l !� <br /> Payment Type �7k Invoice# Check# �23/S Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />