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Complaint Investigation Form Report M 5104 <br /> �Y <br />'w COMPLAINT ID: 000032973 Site Location: 1950 W 11TH ST Account ID: AR0002542 <br /> Receivedby: EE0000321 OLIVEIRA Received Date: 12/1412010 Print Date:12/14/2010 12:36:02PM <br /> Assigned To: EE0001420 MENDE Assigned Date: 12/1412010 <br /> Program/Element Code:1600-FOOD PROGRAM <br /> Complainant: : <br /> <br /> <br /> Nature of complaint. <br /> (C)PURCHASED PACKAGED WHOLE CHIKCEN (FOSTER FARMS)APPROXIMATELY TWO WEEKS AGO. (C)DISCOVERED A 6-INCH WORM <br /> INSIDE ALONG WITH SEVERAL OTHER WORMS. <br /> Complaint Mode: P Complaint Mode Codes A-Agency Referral B-Bd of Supervisors l City Council C-Counter F-Fax <br /> E-Cade Enforcement M-Mail!Correspondence O-Other EH Unit P-Phone <br /> I-Intemet 1 Email S-Sheriffs Office <br /> --- ------------------------------------------------ <br /> -FACILITY INFORMATION OWNER INFORMATION <br /> =.Facility: FA0002980-SAVE MART 490 Owner: OW0000369-SAVE MART SUPERMARKETS <br /> Site Location 1950 W l 1TH ST RP/DBA <br /> TRACY,CA 95376 RP Address 1800 STANDIFORD AVE <br /> Cross Street ELEVENTH MODESTO,CA 95350-0180 <br /> Mailing Address: PO BOX 4278 Billing Address PO BOX 4278 <br /> MODESTO,CA 95352-4278 MODESTO,CA 95352-4278 <br /> Home 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 b— D Inspector.' <br /> L <br /> ----------- ------------------------------------- ---- <br /> Send Referral to . Referral Letter Sent by <br /> Referral Address Date: <br /> Complaint Status Code: o <br /> 6 <br /> Circle appropriate Status Code <br /> 01-FIELD ABATED 50-LEAD Assessment Performed-No Abatement Required <br /> 02-OFFICE ABATED 52-LEAD Abatement Reqired-See 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 <br /> 06-EHD FACILITY-see Linked PROGRAM FACILITY FILE CL-Case Closed <br /> 07-REFERRED TO OTHER AGENCY <br /> OS-UNABLE TO VERIFY <br /> 10-POSTED SUBSTANDARDIUNSECURED-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 /> i <br /> I <br /> 5104,rp1 <br />