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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE <br /> �CREQUEST# <br /> Mobile Food Unit rJ u <br /> OWNER/OPERATOR <br /> Cygnus Home Service, LLC. CHECK if BILLING ADDRESS <br /> (FACILITY NAME) Schwan's Home Service Truck 519562 <br /> SITE ADDRESS) 575 Industrial Park Drive - Manteca 95337 <br /> Street Number Direetlon I street Name city zip COEe <br /> (HOME Or MAILING A_D_DRESSI(If Different from Site Address) IPO Box 178 <br /> Street Number Street Name <br /> CITY Marshall / STATE MN ZIP 56258 <br /> PHONE#1) APN# LAND USE APPLICATION# <br /> ( 209) 825-2940 <br /> PHONE#2' En. BOS DISTRICT LOCATION CODE <br /> (612) 439-8497 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR', <br /> Nicholas Ma rkott CHECK If BILLING ADDRESS <br /> BUSINESS Nnus Home Service, LLC. d.b.a. Schwan's Home Service PHONE# <br /> AM ' <br /> �Y9 716 994-2779 <br /> HOME or MAILING ADDRESS] FAX# <br /> PO Box 178 (612 ) 439-8497 <br /> CITY Marshall STATE MN ZIP 56258 <br /> BILLING ACKNOWLEDGEMENT: 1, 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 /> 1 also certify that 1 have prepared this application and that the work to be perfortned will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STATE and FEDERAL laws. <br /> APPLICANT'S_SIGNATURE: (?ee ]7 !/Bd DAIEpy;, 11/6/2020 <br /> PROPERTY/BUSINESS ON'NER❑ OPE ATOR/ 'TANAGER ❑ OTHERAUTHORIZEDAGENTM License Administrator <br /> (/APPLICANT is not the BILLING PARTY proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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/site assessment <br /> information t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same a it is <br /> provided to me or my representative. Y <br /> TYPE OF SERVICE REQUESTED: y/ I 0 � F� <br /> COMMENTS: '(/ /e 7 e p/a.�• - -42 62,9K2/I9 6T2 5,2 SF�PqQ 06?0 <br /> R �/N <br /> N /�p�T <br /> MFNT <br /> ACCEPTED BY: /��- EMPLOYEE M DATE: <br /> ASSIGNEDTO: [ �L EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: o 6 P I E: 16 D <br /> Fee Amount: ' (� Amount Paid S' U Payment Date 2b <br /> Payment Type `S,, Invoice# Check# / 3 Receiv6d By: 7,91 <br /> EHD 1125 ^' I n- 1O� SR FORM(Golden Rod) <br /> SREVISED SED 11Ii7/2003 � 1`v <br />