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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 Q� Nl sgon5c3 <br /> OWNER I OPERATOR <br /> Cygnus Home Service, LLC. CHECK If BILLING ADDRESS■ <br /> FACiury NAME Schwan's Home Service Truck 518083 Plate-96161 K2 <br /> SITE ADDRESS 575 Industrial Park Drive Manteca 95337 <br /> Street Number I Direction Street Name city Zip Cade <br /> HOME or MAILING ADDRESS (If Different from Site Address) PO Box 178 <br /> Street Number I <br /> Street Name <br /> Cm Marshall STATE ZIP <br /> MN 56258 <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> ( 507 ) 401-8263 <br /> PHONE#2 En. BOS DISTRICT LOCATION CODE <br /> (612 ) 439-8497 1 11 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> NicK Markott CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# En. <br /> Cygnus Home Service, LLC. 716 1 994-2779 <br /> HOME Or MAILING ADDRESS FAx# <br /> PO Box 178 <br /> ( 612 ) 439-8497 <br /> CITY Marshall STATE MN ZIP 56258 <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: f421WDeJ/B2 DATE: 10 25 2022 <br /> PROPERTY/BUSINESS OWNERE 407PEaOlk/MANAGER ❑ OTHER AUTHORIZED AGENT 1W Business LicenseAnalyst <br /> 1fAPPLiC4Nrisnotthe B1LL1NGPABTP 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 environ I I/I/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available anfl f[ylle�fiNlr it is <br /> provided to me or my representative. REC E <br /> TYPE OF SERVICE REQUESTED: Initial Ins ection OCT 25 2Q2 <br /> COMMENTS: • I , _ 1 E .. - e„O SAN JOAQUIN COUNTY <br /> HEALTENVIRONARTMENT <br /> ACCEPTED BY: t � EMPLOYEE M 9-7-,f-3— DATE: <br /> ASSIGNED TO: EMPLOYEEM 0 -iL-9 3 DATE: <br /> Date Service Complet (if already completed): SERVICE CODE: 06 P 1 E: 1603 <br /> Fee Amount: I <br /> Amount Paid /J-(0,()(6 Payment Date <br /> Payment Type V 58— Invoice# Check# �,� �$,S8 29 Received By.dpj <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> p 10 r-v s <br />