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t f & WIA Complaint Investigation Form Report#: 5104 <br /> COMPLAINT ID: C00046987 Site Location: 2380 W KETTLEMAN LN Account ID: AR0004840 <br /> Received by: EE0000025 SEDRA Received Date: 6/26/2018 Print Date: 6/26/2018 12:12:341'M <br /> Assigned To: EE0001084 RAMIREZ Assigned Date: 6/26/2018 <br /> Program/Element Code:1600-FOOD PROGRAM <br /> Complainant: : <br /> <br /> <br /> Nature of complaint: <br /> COMPLAINANT ALLEGES ON 6/23/18 AT APPROXIMATELY 12:00 PM ONE OF THEIR PATIENTS CONSUMED A COOL RANCH TACO. <br /> APPROXIMATELY A HALF HOUR LATER BECAME ILL WITH SYMPTOMS OF VOMITING AND DIARRHEA.COMPLAINANT ALSO ALLEGES ON <br /> 6/25/18 AT APPROXIMATELY 12:00 PM ONE OF THEIR EMPLOYEES CONSUMED A BEEF BURRITO SUPREME.APPROXIMATELY A HALF <br /> HOUR LATER BECAME ILL WITH SYMPTOM OF DIARRHEA. PLEASE CALL COMPLAINANT WITH FINDINGS. <br /> Complaint Mode: P Complaint Mode Codes A-Agency Referral B-Bd of Supervisors/City Council C-Counter F-Fax <br /> E-Code Enforcement M-Mail/Correspondence O-Other EH Unit P-Phone <br /> [-Internet/Email S-Sheriffs Office <br /> -- ------------------------------------------ <br /> PROPERTY INFORMATION OWNER INFORMATION <br /> Facility:FA0004550-TACO BELL P5424 Owner: OW0000362-JEANELL INC(TACO BELL) <br /> Site Location 2380 W KETTLEMAN LN RP/DBA TACO BELL <br /> LODI,CA 95242 RP Address 2111 W KETTLEMAN LN S"rE E <br /> Cross Street LOWER SACRAMENTO LODI,CA 95242-433 <br /> Mailing Address: 2111 W.Kettleman Lane Suite E Billing Address 2111 W.Kettleman Lane Suite E <br /> LODI,CA 95242--750 LODI,CA 95242--750 <br /> Home Phone :209-334-0636 <br /> Phone :209-369-3359 EXT: Work Phone :209-334-0636 EXT: <br /> District 004-WINN,CHARLES Location Code 02-LODI <br /> APN 05814033 <br /> Date Abated Inspector ID#: ile"IAII <br /> ------------------------------------------------- - <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 /> 06-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 /> ACTIVE HOUSING CASE-NEW COMPLAINT see ACTIVE CASE# S2-Hooked up to public sewer <br /> 8 Alleged FBI-No Major Violations Identified S3-Septic system repaired <br /> 29-Alleged FBI-Major Violations Identified <br /> omplaint Reviewed y: ---i1 <br /> ate: pdate by: Date: <br /> 5104.rp1 <br />