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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # r SERVICE REQUEST # <br /> J� � <br /> Telecommunications <br /> OWNER / OPERATOR <br /> CHECK If BILLING ADDRESS <br /> Frontier California Inc <br /> FACILITY NAME <br /> Frontier California Inc - Manteca CO <br /> SITE ADDRESS 430 W Center Street Manteca 95336 <br /> Street Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 280 S . Locust Street <br /> Street Number Street Name <br /> CITY STATE Zip <br /> Pomona CA 91766 <br /> PHONE #1 EXT. APN # LAND USE APPLICATION # <br /> ( 909 ) 620-5962 i n � o2 t � 0 `1 <br /> PHONE #2 EXT• 010 BOS DISTRICT 00 s7r <br /> ATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Vanessa Ortega CHECK if BILLING ADDRESS Ln6l <br /> BUSINESS NAME PHONE # EXT. <br /> SunWest Engineering Constructors , Inc. 909 536-6458 <br /> HOME Or MAILING ADDRESS FAX # <br /> 4780 Cheyenne Way ( 909 ) 594-6169 <br /> CITY Chino STATE CA ZIP 91710 <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 or <br /> activity will be billed to me or my business as identified on this form . <br /> 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, Standard STATE and FED AL laws. <br /> APPLICANT' S SIGNATURE : & DATE : 6/23/21 <br /> PROPERTY I BUSINESS OWNER ❑ OPERATOR / MANAGER OTHER AUTHORIZED AGENT © Project Manager <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 above <br /> site address , hereby authorize the release of any and all results , geotechnical data and/or environmental/site Lss�e_ssment information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as It Is available and at the same tlm �pylded to me or <br /> my representative . Ill , VIER <br /> TYPE OF SERVICE REQUESTED : it/ Ep <br /> COMMENTS : JUN <br /> saNj 24 ?021 <br /> �HEgLTH�PMF�TAC TY <br /> ARTM6NT <br /> ACCEPTED BY: � t � J� EMPLOYEE # : DATE: <br /> ASSIGNED TO : / , , � 0 ' V EMPLOYEE # : DATE: <br /> Date Service Completed ( if already completed) : SERVICE CODE : / G � 2PIE : _ <br /> Fee Amount : ew Amount Pal � 000 Payment Date 024 <br /> 12) <br /> Payment Type Invoice # Check # ��735027� Received By : <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/17/08 <br />