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Date run 7/6/2015 8:34:01AM SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 Run by . Pagel Faci'iity Information as of 7/6/2015 Record Selection Criteria: Facility ID FA0021776 OWNER FILE INFORMATION Number of facilities for this owner Owner ID OW0017924 Owner Name JUST WINGIN IT INC Owner DBA WING STOP OwnerAddress 2612 BAROLA LN Phone MODESTO, CA 95356 Home Phone 209-572-3544 Work/Business Phone 209-824-9464 Mailing Address 2612 BAROLA LN Location Code MODESTO, CA 95356 Care of TOAL, JIM FACILITY FILE INFORMATION Facility ID / CERS ID FA0021776 Facility Name WING STOP Location 1342 E YOSEMITE AVE MANTECA, CA 95336 Phone 209-824-9464 Mailing Address 2612 BAROLA LN MODESTO, CA 95356 Care of TOAL, JIM Location Code 04 - MANTECA Bos District 005 - ELLIOTT, BOB APN 22120068 EMERGENCY NOTIFICATION CONTACT INFORMATION Contact Name TOAL, JIM Title PRESIDENT Day Phone 209-824-9464 Night Phone 209-572-3544 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 AR0039588 Mail Invoices to Facility Mail Invoices to: Account Name WING STOP Account Balance as of 7/6/2015: $-62.50 New Account ID: : Owner / Facility / Account (Circle One) (Circle One) Transferto Active/Inactve Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete 1624 - RESTAURANT/BAR 21-50 SEATS PR0537768 EE0004589 - KADEANNE LINHARES 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. 1 also certify that all operations will be performed in accordance with all applicable Ordinance Codes andbr Standards and State ancl/or 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 #: