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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # CHECK If BILLING ADDRESS El SERVICE REQUEST # Telecommunications FA0003838 BUSINESS NAME DATE: OWNER / OPERATOR ExT. SunWest Engineering Constructors, Inc. Fee Amount: 909 CHECK If BILLING ADDRESS Frontier California Inc Invoice # FAX# FACILITY NAME 4780 Cheyenne Way Frontier California Inc - Manteca CO 594-6169 CITY Chino SITE ADDRESS 430 W I Center Street Manteca 95336 Street Number Direction Street Name City Zip Code HOME or MAILING ADDRESS (If Different from Site Address) 280S. Locust Street Street Number Street Name CITY STATE ZIP Pomona CA 91766 PHONE #1 EXT. APN # 217-021-04 LAND USE APPLICATION # (909) 620-5962 217-210-70 PHONE #2 ExT. BOS DISTRICT LOCATION CODE ( ) 003 04 CONTRACTOR / SERVICE REQUESTOR REQUESTOR COMMENTS: CHECK If BILLING ADDRESS El Vanessa Ortega DATE: ASSIGNED TO: BUSINESS NAME DATE: PHONE # ExT. SunWest Engineering Constructors, Inc. Fee Amount: 909 536-6458 HOME or MAILING ADDRESS Invoice # FAX# Received By: 4780 Cheyenne Way (909) 594-6169 CITY Chino STATE CA ZIP 91710 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. 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. 1 APPLICANT'S SIGNATURE: U-01-1 DATE: 9/26/2023 PROPERTY / BUSINESS OWNER ❑ OPERATOR /MANAGER d OTHER AUTHORIZED AGENT © Project Manager If APPLICANT 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 t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the same time It IS provided t0 me Or my representative. TYPE OF SERVICE REQUESTED: COMMENTS: ACCEPTED BY: EMPLOYEE #: DATE: ASSIGNED TO: EMPLOYEE #: DATE: Date Service Completed (if already completed): SERVICE CODE: P I E: Fee Amount: Amount Paid Payment Date Payment Type Invoice # Check # Received By: EHD 48-02-025 SR FORM (Golden Rod) 07/17/08