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(�✓� Complaint Investigation Form �. x.- P <br /> Re ort#:51D4 <br /> I <br /> COM Account ID: AR0021335PLAINT ID: C00025272 Site Location: 2808 COUNTRY CLUB BLVD t <br /> Received by: EE0002670 NAIDU Received Date: 1015=06 Print Date: 10/5/2006 4:09:36PM <br /> Assigned To: EE0002670 NAIDU Assigned Date: 101512006 <br /> Pro ramlElement Cad <br /> Complainant: Complainant Not Specified Home Phone <br /> Address Work Phone <br /> Nature of complaint.' <br /> UNAUTHORIZED RELEASE(3 GALLONS)AT DISPENSER#2. <br /> Complaint Mode: P Complaint Mode Codes A-Agency Referral B-Bd of Supervisors/City Council C-Counter <br /> E-Code Enforcement M-Mail I Correspondence O-Other EH Unit P-Phone <br /> --------- ------- --------- --------- --------- ----- <br /> FACILITY INFORMATION OWNER INFORMATION <br /> Facility:FAU012764-SAFEWAY FUEL CENTER#1769 Owner: OW0009944-DENNIS JACOBSEN FAMILY HOLDING <br /> Site Location 2808 COUNTRY CLUB BLVD RP/DBA SAFEWAY STORE#1769 <br /> STOCKTON,CA 95204 RP Address 23433 HATTERAS ST <br /> - WOODLAND HILLS,CA 91367 <br /> Mailing Address: 12265 W BAYAUD AVE,STE 100 Billing Address PO BOX 29096 ' <br /> LAKEWOOD,CO 80228 PHOENIX,AZ 85038-9096 <br /> Nome Phone <br /> Phone Work Phone - <br /> District 003-MOW,VICTOR Location Code 01 -STOCKTON <br /> APN 12118038 <br /> Date Abated jod, G r:Inspecto <br /> Send Referral to Referral Letter Sent by <br /> Referral Address Date: <br /> Complaint Status Code: f <br /> e appropriate Status Code <br /> le <br /> 01- IELD ABATED 14-ENFORCEMENT CASE-Transferred to ER FILE f <br /> 02-OFFICE ABATED 15-ACTIVE HOUSING CASE-NEW COMPLAINT see ACTIVE CASE# <br /> 03-NAI SENT 16-LETTER SENT TO TENANT <br /> 04-NOTICE TO ABATE ISSUED 17-15 DAY LETTER SENT <br /> 05-ENFORCEMENT ACTION INITIATED 18-ENFORCEMENT CASE-Transferred to VECTOR CONTROL FILE <br /> 06-EHD PERMIT FACILITY-see Linked PROGRAM FACILITY FILE 19-ENFORCEMENT CASE-Transferred to WELL PROGRAM FILE <br /> 07-REFERRED TO OTHER AGENCY 20-ENFORCEMENT CASE-Transferred to UIC PROGRAM FILE <br /> 08-UNABLE TO VERIFY 28-FOODBORNE ILLNESS-Unconfirmed 1 No Major Violations <br /> 09-FOODBORNE ILLNESS 29-FOODBORNE ILLNESS-Major Violations Identified <br /> istory <br /> 10-SUBSTANDARD PROPERTY-SEE HOUSING ABATEMENT FILE 50-LEAD HAZ EVALUATION REQUIRED(1) - Complaint a1ri�But-Not <br /> 11-Multiple Complaints-SEE ACTIVE CASE# 51-LEAD HAZ WORK PLAN SUBMITTED(2) Attached B Ud NOt A <br /> 12-ENFORCEMENT CASE-Transferred to LIQUID WASTE FILE 52-LEAD HAZ ABATEMENT IN PROGRESS(3) SCaruled <br /> 13-ENFORCEMENT CASE-Transferred to SOLID WASTE FILE 53-LEAD HAZ VISUAL INSPECT SATISFACTORY(4) <br /> 1/14 rpt <br />