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Complaint Investigation Form Report#:5104 <br /> COMPLAINT ID: C00031850 Site Location: 1950 W 11TH ST Account ID; AR0002542 <br /> Receivedby; EE0007541 FIELD Received Date; 4/7/2010 Print Date: 4/7/2010 2:46:10PM <br /> Assigned To: EE0001699 YOAKUM Assigned Date; 4/7/2010 <br /> Program/Element Code:1600-FOOD PROGRAM <br /> Complainant: : <br /> <br /> <br /> Nature of complaint. <br /> (C)PURCHASED INFANT FORMULA ABOUT TWO WEEKS AGO AND HIS INFANT BECAME ILL. INFANT'S DR SUSPECTED THAT IT WAS THE <br /> FORMULA THAT CAUSED ILLNESS. FORMULA BEST BY DATE WAS THE BEGINNING OF MARCH 2010. (C)COMPLAINED TO FEMALE <br /> MANAGER AFTER INFANT BECAME ILL. TODAY(C)WAS AT STORE AND SAW BEST BUY DATES ON FORMULA THAT SAID APRIL 1,2010. <br /> Complaint Mode' P Complaint Made Codes A-Agency Referral B-Bd of Supervisors/City Council C-Counter F-Fax <br /> E-Code Enforcement M-Mail I Correspondence O-Other EH Unit P-Phone <br /> FACILITY INFORMATION OWNER INFORMATION <br /> Facility:FA0002980-SAVE MART#90 Owner: OW0000369-SAVE MART SUPERMARKETS <br /> Site Location 1950 W 11TH ST RP/DBA i <br /> TRACY,CA 95376 RPAddress 1800 STANDIFORD AVE <br /> Cross Street EAi FI. CORAL LANAA& 1 EL V A MODESTO,CA 95350-0180 <br /> Mailing Address: PO BOX 4278 Soling Address PO BOX 4278 <br /> MODESTO,CA 95352-4278 MODESTO,CA 95352-4278 <br /> Nome Phone :209-577-1600 <br /> Phone :209-577-1600 Work Phone :209-574-6275 <br /> District 005-ORNELLAS,LEROY Location Code 03-TRACY <br /> APN 23402010 <br /> Date Abated 0,16 Inspector.' <br /> Send Referral to Referral Letter Sent by <br /> Referral Address Date: <br /> Complaint HistorY <br /> Attached But Not <br /> Complaint Status Code: scanned <br /> Circle appropriate Status Code <br /> 01-FIELD ABATED 50-LEAD Assessment Performed-No Abatement Required <br /> 02-OFFICE ABATED 52-LEAD Abatement Regired-See Program Record File <br /> 03-NA!SENT 97-Disaster Planning and Response { <br /> 04-NOTICE TO ABATE ISSUED 99-UNSPECIFIED-Old Complaint-No Original Found-Pre-tracking <br /> 66>EHD FACILITY-see Linked PROGRAM FACILITY FILE CL-Case Closed <br /> 07-REFERRED TO OTHER AGENCY <br /> 08-UNABLE TO VERIFY <br /> 10-POSTED SUBSTANDARD/UNSECURED-See Housing File <br /> 11-Multiple Complaints-SEE ACTIVE CASE# <br /> 12-DA Referred Complaint-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 /> ' 1 <br /> 510 p1 ' <br />