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Complaint Investigation Form Report#:5104 <br /> COMPLAINT ID: C00032230 Site Location: 2808 COUNTRY CLUB BLVD Account ID: AR0021257 <br /> Received by: EE0009058 LOWE Received Date: 6/23/2010 Print Date: 6/23/2010 3:55:56PM <br /> Assignad To: EE0003474 OM Assigned Date: 6123/2010 <br /> Program/Element Code:1600-FOOD PROGRAM <br /> Complainant: : <br /> <br /> <br /> Nature of complaint <br /> AT 9 PM ON 6!21110,(C)PURCHASED PRE-PACKAGED FUGISAN SUSHI. (C)EXPERIENCED SEVERE STOMACH SWELLING AND SEVERE <br /> VOMITING THAT LASTED THROUGH 6122/10. (C)NOTIFIED.DELI CLERK,AND THEY REMOVED SUSHI FROM COLD SHELVES. <br /> Complaint Mode: p Complaint Mode Codes A-Agency Referral B-Bd of Supervisors 1 City Council C-Counter F-Fax <br /> E-Code Enforcement M-Mail 1 Correspondence O-Other EH Unit P-Phone <br /> I-Internet 1 Email S-Sheriffs Office <br /> ----------------------------------------- <br /> FACILITY <br /> -- ----- ------ ----- ----- ----- <br /> FACILITY INFORMATION OWNER INFORMATION <br /> Facility:FA0012734-SAFEWAY#1769 Owner: OW0009849-DAWES,ROBERT <br /> Site Location 2808 COUNTRY CLUB BLVD RPIDBA SAFEWAY STORE#1769 <br /> STOCKTON,CA 95204 RP Address 5918 STONERIDGE MALL RD <br /> Crass Street 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 :925467-3845 <br /> Phone :209-461-5555 Work Phone :623-869-6100 <br /> District 003-BESTOLARIDES Location Code 01 -STOCKTON <br /> APN 12118043 <br /> Date Abated (V `a,7G Al0- Inspector: *)V <br /> — — T <br /> Send Referral to r Referral Letter Sent by <br /> Referral Address Date: <br /> omplaint History <br /> Attached But Not <br /> Complaint Status Code:1 Seamed <br /> Circle appropriate Status Code <br /> 01 -FIELD ABATED 50-LEAD Assessment Performed-No Abatement Required <br /> 02-OFFICE ABATED 52-LEAD Abatement RegiredSee Program Record File <br /> 03-NAI SENT 97-Disaster Planning and Response <br /> 04-NOTICE TO ABATE ISSUED 99-UNSPECIFIED-Old Complaint-No Original Found-Pre-tracking <br /> 06 EHD FACILITY-see Linked PROGRAM FACILITY FILE CL-Case Closed <br /> 07-REFERRED TO OTHER AGENCY <br /> 08-UNABLE TO VERIFY <br /> 10-POSTED SUBSTANDARDIUNSECURED-See Housing File <br /> 11-Multiple Complaints-SEE ACTIVE CASE# <br /> 12-DA Referred Complaini-See Violation Tracking Form <br /> 15-ACTIVE HOUSING CASE-NEW COMPLAINT see ACTIVE CASE# <br /> 28-FOODBORNE"ILLNESS-No Major Violations Identified <br /> 29-FOODBORNE ILLNESS-Major Violations Identified <br /> 5� rpt <br />