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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY IDJ SERVICE REQUEST # <br /> Telecommunications � o 00-WNGGA - )ZOO <br /> '1 <br /> s <br /> OWNER / OPERATOR <br /> CHECK If BILLING ADDRESS <br /> Verizon Business Purchasing , LLC <br /> FACILITY NAME <br /> Mid City Ca FO Re en <br /> SITE ADDRESS 13850 Devries Road Lodi 95242 <br /> Street Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) P . O . Box 152295 <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> Irving TX 75015 <br /> PHONE #1 EXT, APN # LAND USE APPLICATION # <br /> ( 909 ) 879-2712 D Q <br /> PHONE #2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) l <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Vanessa Ortega CHECK If BILLING ADDRESS <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 /> 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, ST TE and FEDERAL WS. <br /> APPLICANT' S SIGNATURE : DATE : 10/ 19/21 <br /> PROPERTY I BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT ElProject 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 assessment information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the same ti <br /> Ci Ig provided tome or <br /> my representative . / � S R Q I� �//� <br /> TYPE OF SERVICE REQUESTED : ` � `/ <br /> IV <br /> COMMENTS : (, <br /> N �/O r <br /> SA <br /> A <br /> ' HEA THD" ON COU <br /> rMENT <br /> ACCEPTED BY: wX, i J <br /> EMPLOYEE #: DATE : <br /> ASSIGNED TO : vVI ` c 1V_Q, EMPLOYEE #: DATE: IC72 Z <br /> Date Service Completed ( if already completed) : SERVICE CODE: 1g00 —2 F P / E : 21; �og <br /> Fee Amount: 044 760 vu Amount Pai 4&t r� Payment Date / <br /> Payment Type �' Invoice # Check # 133 31 g Red ive By : <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/17/08 <br />