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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # - <br /> Telecommunications FA0003838 S ZOO 8 7 2 5 (9 <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 # 217-021 -04 LAND USE APPLICATION # <br /> ( 909 ) 620-5962 217 -210-70 <br /> PHONE #2 EXT. BOS DISTRICTLOCATION CODE <br /> ( ) 003 704 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Vanessa Ortega CHECK If BILLING ADDRESS <br /> ��)p <br /> BUSINESS NAME PHONE # ExT. <br /> SunWest Engineering Constructors , Inc. 90g 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, Standards, STATE and FEDERAL laws . <br /> APPLICANT ' S SIGNATURE : DATE ; 9/26/2023 <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / MAN 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 assessment information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the Same time It Is provided to me or <br /> my representative . P <br /> TYPE OF SERVICE REQUESTED : t% C N <br /> COMMENTS : <br /> S'4 IV SEP ? 8 ?023 <br /> HEATH DQpMF /CN <br /> VO� TY <br /> A R TMtN <br /> ACCEPTED BY : S1 7i (. EMPLOYEE # : DATE: <br /> ASSIGNED TO : (• l EMPLOYEE # : DATE : / „ 12. ,; 5 <br /> Date Service Completed ( if already completed) : SERVICE CODE : C � 2z4� P I E : / <br /> Fee Amount: coo Amount Pai � Payment Date 1- <br /> Payment Type Invoice # Check # I 4�1Cr 3 / 64 Receiv d By : <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/17/08 <br />