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Date run 12/7/2015 11:26:55AI SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br />Run by Pagel <br />Facility Information as of 12/7/2015 <br />Record Selection Criteria: Facility ID FA0017922 <br />OWNER FILE INFORMATION Number of facilities for this owner <br />Owner ID <br />OW0014718 <br />Owner Name <br />ARMADILLO HOLDINGS LLC <br />Owner DBA <br />TRACY ROADHOUSE LLC <br />Owner Address <br />13099 PARKSIDE DR <br />S*I G 3toq <br />FISHERS, IN 46038-8878 <br />Home Phone <br />765-425-0254 <br />Work/Business Phone <br />801-272-3309 <br />Mailing Address <br />13099 PARKSIDE DR <br />FISHERS, IN 46038-8878 <br />Care of <br />ARMADILLO HOLDINGS LLC <br />FACILITY FILE INFORMATION <br />Facility ID / CERS ID FA0017922 10645990 <br />Facility Name TEXAS ROADHOUSE #703 <br />Location 2422 NAGLEE RD <br />TRACY, CA 95304 <br />Phone 209-830-1133 <br />Mailing Address 13099 PARKSIDE DR <br />FISHERS, IN 46038-8878 <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 12/7/2015: $0.00 <br />Make changes/corrections in RED ink. <br />INFORMATION CHANGE (date) <br />OWNERSHIP CHANGE (date) <br />SSN /Fed Tax ID <br />New Owner ID : <br />eXA,S I w-A►.o(,)se <br />703 <br />S*I G 3toq <br />5'7100 <br />317 588 i!00'208 <br />Alt Phone <br />Fax <br />EMail: <br />a 4-1 <br />�Q <br />S� �to� <br />1828 <br />New Account ID: : <br />Mail Invoices to: Owner / Facility / Account <br />(Circle One) <br />(Circle One) <br />Transfer to Active/Inactve <br />Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br />1626 - RESTAURANT/BAR 101 + SEATS PR0526473 EE0001420 - MELISSA NISSIM Active Y N I D <br />1921 - HMBP-Regular-Primary Location PR0540287 EE0000010 - PETER LOMBARDI Active Y N �; I D <br />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 <br />or activity will be billed to the party identified as the OWNER on th's form. I also certify that all operations will be performed in accordance with all applicable Ordinance Codes andlor Standards and State andlor <br />Federal Laws. <br />" �vAPPLICANT'S SIGNATURE: Date Fes` / /6 <br />Program Records to be TRANER " $25.00 = Amount Paid Date <br />Water Syste to be TR FERED: Amount Paid Date <br />Payme a Check Number Received by <br />EHD tall: Date �/�/ i Account out: �� Date <br />COMM TS: <br />Invoice #: <br />t&4 Mk-tin�, INnu� /dtlL tn T2s , <br />