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Complaint Investigation Form Report#: 5104 <br /> COMPLAINT ID: C00047230 Site Location: 3201 W BENJAMIN HOLT DR#155 Account ID: AR0001793 <br /> Received by: EE0000025 SEDRA Received Date: 8/10/2018 Print Date: 8/10/2018 4:35:41 PM <br /> Assigned To: EE0006213 PEDRAZA Assigned Date: 8/10/2018 <br /> Program/Element Cpdc1600-FOOD PROGRAM <br /> Complainant: :MARK BERBOWER Nome Phone 209-405-1088 <br /> Address Work Phone <br /> Mai!Address <br /> Nature ofcomplaint: <br /> F <br /> MPLAINANT ALLEGES THEY WERE AT THE FACILITY ON 7/27/2018 AT APPROXIMATELY 6:00 PM,COMPLAINANT CONSUMED EGGS AND <br /> AK.CHILD CONSUMED A CHILD'S MEAL.SPOUSE CONSUMED A BURRITO.THE NEXT DAY COMPLAINANT AND CHILD BECAME ILL WITH <br /> PTOM OF DIARRHEA.COMPLAINANT SOUGHT MEDICAL ATTENTION AND WAS DIAGNOSED WITH E-COLI. PLEASE CALL COMPLAINANT <br /> H FINDINGS. <br /> Complaint Mode: P Complaint Mode Codes A-Agency Referral B-Bd of Supervisors I City Council C-Counter F-Fax <br /> E-Code Enforcement M-Mail 1 Correspondence O-Other EH Unit P-Phone <br /> I-Internet!Email S-Sheriff's Office <br /> ------------------------------------------------- <br /> PROPERTY INFORMATION OWNER INFORMATION <br /> Facility:FA0001793-OCTAVIO'S Owner: OW0012778-CRUCES FLORES LLC ��/f <br /> Site Location 3201 W BENJAMIN HOLT DR STE 155 RP/DBA OCTAVIO'S (duM o <br /> STOCKTON,CA 95219 RPAddress 9028 BRIDALVEIL CIR p <br /> Cross Street HERNDON STOCKTON,CA 95212 <br /> Mailing Address: 3201 W BENJAMIN HOLT DR STE#155 Billing Address 9028 BRIDALVEIL CIR <br /> STOCKTON,CA 95219 STOCKTON,CA 95212 <br /> Nome Phone :209-993-5326 <br /> Phone :2094151-1116 Work Phone :209-451-1116 <br /> District 002-MILLER,KATHERINE Location Code O1-STOCKTON <br /> APN 10017009 1, N <br /> Date Abated Inspector ID#: �7ji3� tIL " <br /> Send Referral to Referral Letter Sent by <br /> Referral Address Date: <br /> Complaint Status Code: <br /> Circle appropriate Status Code <br /> 01-Field Response-Violations Cited and Corrected 50-LEAD Assessment Performed-No Abatement Required <br /> 02-Office Response Only 52-LEAD Abatement Reqired-See Program Record File <br /> OB-Violations Cited-see Linked PROGRAM FACILITY FILE 97-Disaster Planning and Response <br /> 07-Refferred to Other Agency 99-UNSPECIFIED-Old Complaint-No Original Found <br /> 08-Unable to Verify Alleged Complaint MN-EHD Monitoring Status <br /> 10-POSTED SUBSTANDARD/UNSECURED-See Housing File PD-Permit Issued-Pending Well Installation <br /> 11-Multiple Complaints-SEE ACTIVE CASE# RS-Resolved-New Well Installed <br /> 12-DA Referred Complaint-See Program Enforcement Action Form S1-Tank pumped <br /> 15-ACTIVE HOUSING CASE-NEW COMPLAINT see ACTIVE CASE# S2-Hooked up to public sewer <br /> 28-Alleged FBI-No Major Violations Identified S3-Septic system repaired <br /> 29-Alleged FBI-Major Violations Identified <br /> omp aini Reviewed by: Updated bte; <br /> 5104.rp1 <br />