Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />Jay Johnson <br />�-{� 0670 6 6 5 <br />S)� 0 u -gSq Li <br />Mobile Food Unit <br />PHONE # <br />OWNER/ OPERATOR <br />Cygnus Home Service, LLC. <br />Cygnus Home Service, LLC. <br />CHECK if BILLING ADDRESS <br />FACILITY NAME <br />HOME or MAILING ADDRESS <br />Schwan's Home Service Truck 518035 -Plate 326741-2 <br />FAX# <br />SITE ADDRESS �� <br />PO Box 178 <br />isA� 0_ / D ✓r v,C <br />OVe 1{ <br />Street Number <br />DlrecHan <br />treeel Name <br />LP 56258 <br />Clt Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />PO Box 178 <br />I <br />Street Number <br />Street Name <br />CITY STATE <br />ZIP <br />Marshall MN <br />56258 <br />PHONE#1 Em <br />APN # <br />LAND USE APPLICATION # <br />( 507 ) 401-8360 <br />PHONE #2 En. <br />BOS DISTRICT <br />LOCATION CODE <br />(612 ) 439-8497 <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />Jay Johnson <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME <br />PHONE # <br />E". <br />Cygnus Home Service, LLC. <br />916 <br />207-1738 <br />HOME or MAILING ADDRESS <br />FAX# <br />PO Box 178 <br />( 612 ) <br />439-8497 <br />CITY Marshall <br />STATE MN <br />LP 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: teff Y �p J/gy DATE: 10 25 2022 <br />PROPERTY I BUSINESS OWNER PE OR/MANAGER❑ OTHER AUTHORIZED AGENT i Business License Analyst <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/site assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as it is available and at the Same time it is <br />provided to me or my representative. pd V e . _ <br />TYPE OF SERVICE REQUESTED: Initlallns action RIt: C "'r <br />COMMENTS: / t / / � OCT SAN JOA 2 5 ?022 <br />ENVIR NINCOUNTy <br />HEALTH 1) ART7AL. <br />ACCEPTED BY: -t EMPLOYEE #: .�— �� DATE: <br />ASSIGNEDTO: EMPLOYEE#: �gg DATE: l <br />Date Service Completed (if already completed): SERVICE CODE: D&,r PIE: 1663 <br />Fee Amount:- 1!;-6 Amount Paid /SZ l)o Payment Date � 2 <br />Payment Type i I Invoice # Check # /,S7 SgS g�9 I Receive By: <br />EHD 48-02-025 <br />REVISED 11/17/2003 <br />SR FORM (Golden Rod) <br />1 <br />