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Date run: 07/28/9 AN JOAQUIN COUNTY PUBLIC HEALTH SERVIC Report 05104 <br /> Run by_.� = CAROL Page <br /> # 1 <br /> Copy # 01 of 01 COMPLAINT INVESTIGATION REPORT <br /> COMPLAINT # C0010725 Program/Element : 1625 <br /> Taken by : 7829 GAGAZA Date: 07/28/98 Assigned to : 0467 CARRUESCO Date:. P7/28/98, ' <br /> Hard copy Printed. <br /> ;a <br /> Facility Name: ROUNDTABLE PIZZA Fac ID : 037 <br /> .......... <br /> BILL to inventoried FACILITY: <br /> Location= 320.1.. W..,._BF_NJAM.T.N HOLT....._DR.....9_1 (Must have FACILITY 100) <br /> Complainant: MARGARET JACOBSON/TTM HOESERT................---Home Phone : 209-957--2469 <br /> Address: Work Phone : <br /> FACILITY LOCATION/Property Info - <br /> i <br /> DBA or Name ROUND._...T@LE......PTZZ.A_.....,_................_,........................,_.........................................._._..._.........._..__................_. <br /> Lac Code 0.3.. <br /> Address : 3201 ,W ._B N_�_AMfN HOLT... DR.. 91 _. .............. ................... .... . .. BOS Dist <br /> City: ST_OCKTON. 95219 APN # <br /> Phone <br /> BILLING RESPONSIBLE PARTY or OWNER Info - <br /> Name : H&H. PI ZZA...,...__T_NG......... . ........ _:,....._...:...................._Home Phone : 209--333-3755 <br /> Address: 628....CF_NTRAL.....AVE............_..._......_.....-. ___.,._............................................... ......_.Work Phone: 209-'832--8030 <br /> City : TRACY CA 95376 <br /> I$ <br /> Nature of Complaint: <br /> PEPPERONI , CHICKEN AND VEGETABLE PIZZA . BECAME ILL WITH BAD STOMACH <br /> ACHE , CRAMPING , DIARRHEA , NAUSEA . ALL FOUR PEOPLE BECAME SICK . <br /> w <br /> COMPLAINT Info - <br /> COMPLAINT MODE: P PHONE <br /> A-Agency Referral B-BD OF Supervisors/City CCOUnCll C-Counter M-Mail/Correspondence <br /> O-Other EH Unit P-Phone <br /> COMPLAINT STATUS: V� <br /> 01-Field Abated 02-Office Abated 03-NAI Sent 04-Notice to Abate Issued 05-Enforce ACT Initiated <br /> 06-Transfer to Premise File 07-Refer to Other AgencyNot Valid 09-Foodborne Illness <br /> v <br /> Send Referral Letter to: <br /> Address: <br /> Referral Letter Sent by : Date: <br /> Circle appropriate Unit 4 if complaint in another PROGRAM jurisdiction, Have Complaint Record and PIE updated <br /> Forwarded to UNIT: II III IV for Investigation <br /> 3 <br /> a <br />