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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/ Banquet Hall a 23 SR00 <br /> OWNER I OPERATOR <br /> Parkwest Casino Manteca LLC CHECK if BILLING ADDRESS <br /> FACILITYNAME Ernie's Food & Spirits <br /> SITE ADDRESS 1351 N. Main St. Manteca 95336 <br /> Street Number Direction I Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 1100 S. Flower St., #3100 <br /> Street Number Street Name <br /> CITY Los Angeles STATE CA ZIP 90015 <br /> PHONE#1 Ex. APN# LAND USE APPLICATION# <br /> ( ) (323) 263-2632 <br /> PHONE#2 Ex . BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Jeff Van Wagner CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# Exr. <br /> Parkwest Casino Manteca LLC I 1 (323) 415-4928 <br /> HOME Or MAILING ADDRESS 1100 S. Flower St., #3100 FAx# <br /> 1 ) <br /> CITY Los Angeles STATE CA ZIP 90015 <br /> BILLING ACKNOWLEDGEMENT: 1, 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 <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 /> COUN'T'Y Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: ,.,,- DATE: Dec 17,2021 <br /> PROPERTY/BUS IN ESS OWN ER 13 OPERATOR/MANAGER ❑ OTBERAUTHORIZED AGENTM Attorney <br /> IfAPPLICANT 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 <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. C <br /> TYPE OF SERVICE REQUESTED: PAYMENT <br /> COMMENTS: ( r, .` <br /> •,/J'r�✓..n, -"„""/Avit � � DEC 17 2021 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: n EMPLOYEE#: DATE: <br /> ASSIGNEDTO: EMPLOYEE#: �O �$$ DATE: <br /> 642FeDate Service Comple d (If already completed): SERVICE CODE: 6 PIE: 16o2- <br /> Fee <br /> e Amount: L 6� Amount Paid Payment Date 1 .7-//:Z( <br /> Payment Type mr Invoice# JChec33 Received By: <br /> 17 <br /> EHD 48-02-025 SR FOAM(Golden Rod) <br /> REVISED 11/17/2003 ��� � <br />