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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Restaurant NNI�p 0 J 2 <br /> OWNER/OPERATOR Parkwest Casino Manteca LLC ❑ <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME Parkwest Casino Manteca <br /> SITE ADDRESS 1355N Main St. Manteca 95336 <br /> Stroet Number .,.N. SVeet Name Ci Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 1100 S. Flower St., #3100 <br /> Street Number Street Na.. <br /> CITY Los Angeles STATE CA ZIP 90015 <br /> PHONE#1 EXT, APN# LAND USE APPLICATION# <br /> ( ) (323) 263-2632 <br /> PHONE#2 Ext. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Jeff Van Wagner 3 } I? 3 z( S01 s} <br /> CHECK if BILLING ADDRESS 09 <br /> BUSINESS NAME Parkwest Casino Manteca LLC PHONE# 323 415-4928 <br /> HOME or MAILING ADDRESS 1100 S. Flower St., #3100 ( <br /> CITY Los Angeles STATE A ZIP 90015 <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 ENVmoNmENTAL 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: w.6!a 01 sa em DATE: Dec 13,2021 <br /> PROPERTY/BUSINESS OWNER[] OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT, Attorney <br /> 1f APPLICANT is not the BILLING PARTY proof of authorization t0 sign is required Tide <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. <br /> TYPE OF SERVICE REQUESTED: PAYMENT <br /> COMMENTS: RECEIVED <br /> DEC 16 2021 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: `�Y�t.� [,�/J EMPLOYEE#: DATE: <br /> ASSIGNED TO: 1 E� EMPLOYEE#: DATE: l <br /> Date Service Completed (If already completed): SERVICE CODE: ro PIE: <br /> Fee Amount: I C2 Amount Paid 115-2— Payment Date I�It� y <br /> Payment Type I' Invoice# Check# 3 6 �( s 9n(0 Received By: <br /> EHD 48-02-025 SR ORM(Golden Rod) <br /> REVISED 11/172003 <br />