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Date run 7/1/2015 3:02:24PM SAN JOAQUIN'*COUNYY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 Run by Pagel Facility Information as of 7/1/2015 Record Selection Criteria: Facility ID FA0017922 OWNER FILE INFORMATION Number of facilities for this owner: 1 Owner ID OW0014718 Owner Name ARMADILLO HOLDINGS LLC Owner DBA TRACY ROADHOUSE LLC Owner Address 201 S CREEDMOOR WAY Phone ANDERSON, IN 46011 Home Phone 765-425-0254 Work/Business Phone 801-272-3309 Mailing Address 33 W TENTH ST STE 802 Location Code ANDERSON, IN 460161435 Care of ARMADILLO HOLDINGS LLC FACILITY FILE INFORMATION Facility ID/CERS ID FA0017922 Facility Name TEXAS ROADHOUSE #703 Location 2422 NAGLEE RD TRACY, CA 95304 Phone 209-830-1133 Mailing Address 33 W TENTH ST STE 802 ANDERSON, IN 460161435 Care of ARMADILLO HOLDINGS LLC Location Code 03 -TRACY BOS District 005 - ELLIOTT, BOB APN 21229043 EMERGENCY NOTIFICATION CONTACT INFORMATION Contact Name STEPHEN MADINGER Title OWNER Day Phone 209-830-1133 Night Phone 765-425-0254 Make changes/corrections in RED ink. INFORMATION CHANGE (date) OWNERSHIP CHANGE (date) SSN / Fed Tax ID New Owner ID : Alt Phone Fax EMail : ACCOUNTS RECEIVABLE FILE INFORMATION Account ID AR0031433 Mail Invoices to Facility Mail Invoices to: Account Name TEXAS ROADHOUSE #703 Account Balance as of 7/1/2015: $0.00 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 1626 - RESTAURANT/BAR 101 + SEATS PR0526473 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 andror Federal Laws. APPLICANT'S SIGNATURE: Program Records to be TRANSFERED: Water System to be TRANSFERED: Payment Type Check Number EHD Staff: COMMENTS: $25.00 = Date ! / Date / !, Amount Paid Date _ Amount Paid Date Received by Account out: Date Invoice #: