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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> �Type of Business or Property) FACILITY ID# SERVICE REQUEST# <br /> Mobile Food Unit f A 0 a �j VV a <br /> OWNER/_OPERATOR�� <br /> Cygnus Home Service, LLC. CHECK If BILLING ADORESSn <br /> (FACILITY NAMEi Schwan's Home Service Truck 519562 <br /> �Sm:ADDREssI 575Industrial Park Drive Manteca 95337 <br /> Street Num Dar I Direction Street Name city 7JCMo <br /> (HOME or MAILING ADDRESS)(If Different from Site Address) PO Box 178 <br /> Street Number Street Name <br /> CITY Marshall I STATE MN ZIP 56258 <br /> PHONE#lj En. APN# LAND USE APPLICATION# <br /> ( 209) 825-2940 <br /> PHONE#2', En. BOS DISTRICTLOCATION CODE <br /> (612 ) 439-8497 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR' <br /> Nicholas Markott CHECK If BILLING ADDRESS <br /> BUSINESS NAM ? nus Home Service, LLC. d.b.a. Schwan's Home Service PHONE# En. <br /> 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 /> 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'SSIGNATURE: �l1 D¢I�rgd DAf/rE <br /> -. 11/6/2020 <br /> PROPERTY/BUSINESS OWNER❑ OPE TOR/ 4ANAGF.R ❑ OTHERAUTHORIzEDAGF.N"rM License Administrator <br /> Ir l PPLICANT is not the BILLING PAR 7Y 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 to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the sam&jpre it is <br /> provided to me or my representative. ;Z. y <br /> TYPE OF SERVICE REQUESTED: }/ �'e (J' (;,� <br /> COMMENTS: '7' `�F`o e plI 2 62 9k2 j1,5-6-,2 5.2 <br /> O <br /> / Nuc?& 0 4f,NTUN <br /> / MFN <br /> ACCEPTED BY: /n �— EMPLOYEE#: DATE: <br /> ASSIGNED TO: �hjRuL EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 4961 PIE: 16 <br /> Fee Amount: I (� Amount Paid S2.vD Payment Date i;, Zb <br /> Payment Type `S 6- Invoice# Check# / (,S563G Receiv6dBy: <br /> EHDREV SED 11/1 ��0 54 -) P n- �10� SR FORM(Golden Rod) <br /> REVISED 11/172003 1"u d) <br />