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Date run 7/8/2015 2:00:10PM SAN JOAQUIN COATY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 Run by Pagel Facility Information as of 7/8/2015 Record Selection Criteria: Facility ID FA0002984 OWNER FILE INFORMATION Number of facilities for this owner Owner ID OW0016033 Owner Name WINGS IN MOTION INC Owner DBA WINGSTOP Owner Address 1063 CHESHIRE CIR DANVILLE, CA 94506 Home Phone 925-260-3605 Work/Business Phone 925-260-3605 Mailing Address 1063 CHESHIRE CIR DANVILLE, CA 94506 Care of BHASIN, RANJAN (VP) FACILITY FILE INFORMATION Facility ID / CERS ID FA0002984 Facility Name WINGSTOP Location 1988 W ELEVENTH ST TRACY, CA 95376 Phone 209-836-9464 Mailing Address 2612 BARLOA LN MODESTO, CA 95356 Care of JIM TOAL Location Code 03 -TRACY Bos District 005 - ELLIOTT, BOB APN 23402012 EMERGENCY NOTIFICATION CONTACT INFORMATION Contact Name JIM TOAL Title PRESIDENT Day Phone 209-985-5700 Night Phone 209-985-5700 ACCOUNTS RECEIVABLE FILE INFORMATION Account ID AR0002546 Mail Invoices to Facility Account Name WINGSTOP Account Balance as of 7/8/2015: $0.00 Make changes/corrections in RED ink. INFORMATION CHANGE (date) OWNERSHIP CHANGE (date) SSN / Fed Tax ID New Owner ID : Alt Phone Fax EMail : Mail Invoices to: New Account ID: : Owner / Facility / Account (Circle One) (Circle One) Transfer to Active/Inactve Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete 1624 - RESTAURANT/BAR 21-50 SEATS PRO163335 EE0001420 - MELISSA NISSIM Active Y N A I D BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site, and/or project specific, PHS/EHD hourly charges associated with this facility or activity will be billed to the party identified as the OWNER on this form. I also certify that all operations will be performed in accordance with all applicable Ordinance Codes and/or Standards and State and/or Federal Laws. APPLICANT'S SIGNATURE: Program Records to be TRANSFERED: Water System to be TRANSFERED: Payment Type Check Number EHD Staff: COMMENTS Date * $25.00 = Amount Paid Date Amount Paid Date / Date Received by Account out: Date Invoice #: