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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEST # Mobile Food Unit f7& uoi�-NLPSJ SQ O0gLJLAW 2, OWNER/ OPERATOR CHECK If BILLING ADDRESS Cygnus Home Service, LLC. MN Zip 56258 FACILITY NAME Schwan's Home Service Truck 518333 EMPLOYEE #: SITE ADDRESS 575Industrial I ASSIGNED TO: ' Park Drive I Manteca 95337 Street Num bar Direction Fee Fee Amount: Street Name city Zip Code HOME or MAILING ADDRESS (If Different from Site Address) Check # O 3 PO Box 178 I Street Number Street Name CITY Marshall STATE MN Zip 56258 PHONE #1 ExT' APN # LAND USE APPLICATION # ( 612) 314-0518 PHONE #2 Em BOS DISTRICT LOCATION CODE (612) 439-8497 CONTRACTOR / SERVICE REQUESTOR REQUESTOR Nicholas Markott CHECK If BILLING ADDRESS BUSINESS NAMPHONE# FCygnus Home Service, LLC. d.b.a. Schwan's Home Service EXT. (612)314-0518 HOME or MAILING ADDRESS FAX # PO Box 178 (612) 439-8497 CITY Marshall STATE MN Zip 56258 BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. 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 COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. APPLICANT'S SIGNATURE: COZ4 Z% //92 DATE:: 111/10/2021 PROPERTY/BUSINESS OWNER❑ OPE TOR/ ANAGER 11OTHERAUTHORIZEDAGENT M Business License Analyst_ IfAPPLICANP is not the BILLING PARTY proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: RF . COMMENTS: V AED DEC 20 SA20 N,, 21 0 q NEq�THa�pgRTN CNTy ACCEPTED BY: r F - EMPLOYEE #: DATE: 17 — M — 2 ASSIGNED TO: ' EMPLOYEE #: DATE: Date Service Completed (if already Completed): SERVICE CODE: �,�j PIE: o 2— Fee Fee Amount: Amount Paid Z d� Payment Date i Payment Type Invoice # Check # O 3 Receiv By: EHD 48-02-025 REVISED 11/17/2003 SR FORM (Golden Rod) S