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Complaint Investigation Form Report#:5104 <br /> COMPLAINT lD C00028703 Site Location: 2808 COUNTRY CLUB BLVD AccountfD: AR0021335 <br /> Received by: EE0005642 HENRY Received Date: 7/21/2008 Print Date: 7/22/2008 4:14:26PM <br /> Assigned To: EE0005642 HENRY Assigned Date: 7/22/2008 <br /> Proram/Element Code 2547-GENERATOR RESPONSE STANDBY <br /> Complainant: ;VEEDER-ROOT Nome Phone <br /> Address Work Phone <br /> Nature of com Taint: <br /> 112-1 GALLON OF FUEL SPILLED BY CUSTOMER AT DISPENSER#6. <br /> Complaint Mode: A Complaint Mode Codes A-Agency Referral B-Bd of Supervisors I City Council C-Counter <br /> E-Code Enforcement M-Mail!Correspondence O-Other EH Unit P-Phone <br /> --------- -------- — ._ ----- ----------- <br /> FACILITY INFORMATION OWNER INFORMATION 1 <br /> Facility:FA0012764-SAFEWAY FUEL CENTER#1769 Owner: OW0009944-DENNIS JACOBSEN FAMILY HOLDING t <br /> i <br /> Site Location 2808 COUNTRY CLUB BLVD RP/DBA SAFEWAY STORE 41769 <br /> STOCKTON,CA 95204 RP Address 23433 HATTERAS ST <br /> WOODLAND HILL53 CA 91367 <br /> Mailing Address., PO BOX 29096 Billing Address PO BOX 29096 <br /> PHOENIX,AZ 85038-9096 PHOENIX,AZ 85038-9096 <br /> Home Phone <br /> Phone Work Phone 1-2z I <br /> District 003-MOW,VICTOR Location Code 01-STOCKTON <br /> APN 12118038 <br /> Date Abated 'L`L ( Inspector: L'J br f1 <br /> �ff ——— ------------------------ <br /> Send <br /> --------- ------ --Send Referral to 'slit Referral Letter Sent by <br /> Referral Address –-- 1(( Date: <br /> Complaint Status Code:` r <br /> A V <br /> Circle appropriate Status Code <br /> 0 -FIELD ABATED 14-ENFORCEMENT CASE-Transferred to ER FILE <br /> 02OFFICE ABATED 15-ACTIVE HOUSING CASE-NEW COMPLAINT see ACTIVE CASE# <br /> NAI SENT 16-LETTER SENT TO TENANT <br />{ 04-NOTICE TO ABATE ISSUED 17-15 DAY LETTER SENT l <br /> 05-ENFORCEMENT ACTION INITIATED 18-ENFORCEMENT CASE-Transferred to VECTOR CONTROL FILE <br /> 05-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 f 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 Complaint History <br /> 11-Multiple Complaints-SEE ACTIVE CASE# 31-15 Day Letter Sent-Alleged Complaint Attached But Not <br /> 12-ENFORCEMENT CASE-Transferred to LIQUID WASTE FILE 50-LEAD HAZ EVALUATION REQUIRED(1) Scanned <br /> I 13-ENFORCEMENT CASE-Transferred to SOLID WASTE FILE 61-LEAD HAZ WORK PLAN SUBMITTED(2) <br /> i <br /> I <br /> a <br /> I <br /> 5104 1 <br />