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Dote run 7/812015 44-WM SAN JO, JI IN C04NTY ENVIRONMENTAL HEA I DEPARTMENT Keponasol7 <br />Run by Papel <br />L� / fD Facility Information as of 7/8/2015 <br />Record Seleebon Criteria' Facility ID FA0017922 <br />OWNER FILE INFORMATION Number of facilities for this owner <br />Owner ID OW0014718 <br />Owner Name ARMADILLO HOLDINGS LLC <br />Owner DBA TRACY ROADHOUSE LLC <br />Owner Address 201 S CREEDMOOR WAY <br />ANDERSON, IN 46011 <br />Home Phone 765-425-0254 <br />WorkJBusiness Phone 801-272-3309 <br />Mailing Address 33 W TENTH ST STE 802 <br />ANDERSON, IN 460161435 <br />Care of ARMADILLO HOLDINGS LLC <br />FACILITY FILE INFORMATION <br />Facility ID! CERS ID FA0017922 <br />Facility Name TEXAS ROADHOUSE #703 <br />Location 2422 NAGLEE RD <br />TRACY, CA 95304 <br />Phone 209-830-1133 <br />Mailing Address 33 W TENTH ST STE 802 <br />ANDERSON, IN 460161435 <br />Care of ARMADILLO HOLDINGS LLC <br />Location Code 03 -TRACY <br />BOS District 005 - ELLIOTT. BOB <br />APN 21229043 <br />EMERGENCY NOTIFICATION CONTACT INFORMATION <br />Contact Name STEPHEN MADINGER <br />Title OWNER <br />Day Phone 209-830-1133 <br />Night Phone 765-425-0254 <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />Account ID AR0031433 <br />Mail Invoices to Facility <br />Account Name TEXAS ROADHOUSE #703 <br />Account Balance as of 7/8/2015: $0.00 <br />Make changes/corrections in RED ink. <br />INFORMATION CHANGE (date) I01I /'`!i5 <br />OWNERSHIP CHANGE (date) <br />SSN / Fed Tax ID . <br />New Owner ID : <br />Alt Phone <br />Fax <br />EMail <br />;�rogra.•rvElernent and Description Record ID Employee ID and Name <br />New ACCOLnt ID. <br />Mail Invoices to Owner / Facility / Account <br />icicle one) <br />(Circle One) <br />Transfer to Activeliractve <br />Status New Owner) Delete <br />1626 - RESTAURANT/BAR 101 + SEATS PR0526473 EE0001420 - MELISSA NISSIM Active Y N A 1 D <br />1921 - HMBP-Regular-Primary Location PRO540287 EE0000010 - PETER LOMBARDI Active Y N A I D <br />BALLING and COMPLIANCE ACKNOWLEDGEMENT I.:t e undersigned owner. operator or agent or sane, ackrwwtedge that all silo. andior protect spioc;fic. PHS/EHO hourly dwpes associated with tri s facility <br />or acl ty will be c0od to the party identified as the OVINER cn [-is form I also cenrfy that alt operations will be performed in accordance w;C+ all spplcable Ordinance Codes and'or Standards and State and'or <br />FeKwal Laws. <br />r � <br />APPLICANTS SIGNATURE Z Date A <br />Program Records to be TRANSFEE� , ' $25.00 = Amount Paid Date / J <br />Water System to be TRANSFERED: Amount Paid Date ! ! <br />Payment Type Check Number Received by <br />EHD Staff: Date / / Account out f" > Date IZS <br />rouu: ruT c <br />cit � rrYc.�t o� <br />Invoice #: _ <br />ld y rYlu�Gt.t t&L el 1, /i S �a A? c ' A 'hc . - <br />