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Report+•� �' <br /> Complaint lnVe5tigation Form <br /> Account!D: AR0021257 <br /> COMPLAINT ID: C00025617 Site Location: 2808 <br /> COUNTRY CLUB BLVD print Date:1211912006 1:05:24PM <br /> Received Date: 1211912006 <br /> Received by: EE0007541 FIELD Assigned Date: 121`1912006 <br /> Assigned To: EE0000149 BORGES SCAM n <br /> P om/Element Code:160O <br /> 0-FD PROGRAM Home Phone : 209-463-6755 S A�L <br /> Complainant: :BLANCHE INGRAHAM Work Phone : <br /> Address <br /> L,PRE-Nature of col plaint: <br /> ON 12/17/06 AROUND 5 PM,CHICKEN W NGS,ANDA URICIEYlLETTUCE T MATTO RWRAP. (C)ATE CH CKEN AND TURKEYDE OBWRAP ATDHOME <br /> PACKAGE OF TERIYA <br /> BETWEEN 6 AND 7 P1DIARRHEA SLATER I1N THE DAY SHE ATE THE COBB1SALAD AND ABOUT 1C MMSTARTED VOM T G.O(C)1 SISTILL SICK <br /> STILL SICK WITH <br /> ER <br /> TODAY. SHE IS SEEING HER DOCTOR OR NURSE PRACTIONER AT 3:30 PM. """(C)REQUESTS CALL BACK FROM INSPECTOR AFT <br /> INSPECTION.`"` <br /> Complaint Mode: P Complaint Mode Codes A-Agency Referral B-Bd of Supervisors 1 City Council C-Counter <br /> E-Code Enforcement mwo t Correspondence O-Other EH Unit —— P-Phone —— — <br /> FACILITY INFORMATION OWNER INFORMATION <br /> Facility:FA0012734-SAFEWAY#1769 Owner: OW0009949-DAWES,ROBERT <br /> Site Location 2808 COUNTRY CLUB 13LVD RP/DBA SAFEWAY STORE#1769 <br /> STOCKTON,CA 95204 RP Address 5918 STONERIDGE MALL RD <br /> PLEASANTON,CA 94588-3229 <br /> Mailing Address: PO BOX 29096 Billing Address 5918 STONERIDGE MALL RD <br /> PHOENIX,AZ 85038-9096 PLEASANTON,CA 94588-3229 <br /> Home Phone :925-467-3845 <br /> Phone :209-461-5555 Work Phone :623-869-6100 <br /> District 003-MOW,VICTOR Location Code 0 -STOCKTON <br /> APN 12118043 <br /> Date Abated a Inspector, <br /> Send Referral to Referral Le er Sent by <br /> Referral Address Date: <br /> Complaint Status Coder <br /> Circle appropriate Status Cade <br /> 01-FIELD ABATED 14-ENFORCEMENT CASE-Transferred to ER FILE <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 /> 10-SUBSTANDARD PROPERTY-SEE HOUSING ABATEMENT FILE 30-15 Day Letter Sent-Confirmed Complaint <br /> 11-Multiple Complaints-SEE ACTIVE CASE# 31-15 Day Letter Sent-Alleged Complaint <br /> 12-ENFORCEMENT CASE-Transferred to LIQUID WASTE FILE 50-LEAD HAZ EVALUATION REQUIRED(1) <br /> 13-ENFORCEMENT CASE-Transferred to SOLID WASTE FILE 51-LEAD HAZ WORK PLAN SUBMITTED(2) <br /> Completed <br /> 5I04.rpt <br />