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Complaint Investigation Form Report#:5104 <br /> ->~=(-*PLAINT ID: C00020868 Site Location: 1230 W KETTLEMAN LN Account ID: AROO14570 <br /> INReceived by: EE0000321 OLIVEIRA Received Date: 5/25/2004 Print Date: 5/25/2004 4:07:28PM <br /> Assigned To: EE0000467 CARRUESCO Assigned Date: 5/25/2004 <br /> Program/Element Code_1600-FOOD PROGRAM <br /> Complainant: :DENNIS MONTGOMERY Nome Phone 775-851-4148 <br /> Work Phone <br /> Address <br /> Nature of complaint., <br /> FOUR PERSONS ATE AT ABOVE FACILITY5123104 8:00AM-9:OOAM. COMMON FOODS CONSUMED WERE EGGS(BOTH OVER MEDIUM AND <br /> SCRAMBLED)AND BACON AND SAUSAGE. SYMPTOMS BEGAN 11:00 AM-2:00 PM ON 5124104. VOMITING,DIARRHEA,CRAMPS. (Cps <br /> DAUGHTER WENT TO THE E.R. BLOOD AND STOOL SAMPLES WERE TAKEN AND ANALYZED. RESULTS NOT YET KNOWN. <br /> I <br /> Complaint Made: P Complaint Mode Codes A-Agency Referral B-Bd of Supervisors 1 City Council C-Counter <br /> E-Code Enforcement M-Mail 1 Correspondence O-Other EH Unit P-Phone <br /> P <br /> _____ __ __ _ ------- ------ <br /> FACILITY INFORMATION — — OWNER INFORMATION <br /> Facility:FA0003926-IHOP Owner: OW0006538-SEVENTEEN FORTY EIGHT CO,INC <br /> Site Location 1230 W KETTLEMAN LN RP/DBA 1HOP <br /> LODI,CA 95240 RP Address 25020 STANFORD AVE 170 i <br /> VALENCIA,CA 91355 I <br /> Mailing Address: 1230 KETTLEMAN LN Billing Address 1230 KETTLEMAN LN <br /> LODI,CA 95240 LODI,CA 95240 <br /> Home Phone :661-294-8877 <br /> Phone :209-369-1361 Work Phone :209-369-1361 <br /> 1 <br /> District 004-SEIGLOCK,JACK Location Code 02-LODI <br /> APN 06004001 i <br /> Date Abated _ z] —©Lf Inspector. 47 <br /> — <br /> Send Referral to Referral Letter Sent by <br /> Referral Address Date: <br /> I <br /> Complaint Status Code:Z v <br /> Circle appropriate Status Code <br /> 01-FIELD ABATED 14-ENFORCEMENT CASE-Transferred to ER FILE <br /> 02-OFFICE ABATED 15-ACTIVE HOUSING CASE-NEW COMPLAINT see ACTIVE CASE# <br /> 03-NAI SENT 16-LETTER SENT TO TENANT <br /> 04-NOTICE TO ABATE ISSUED 17-15 DAY LETTER SENT <br /> 05-ENFORCEMENT ACTION INITIATED 18-ENFORCEMENT CASE-Transferred t0 VECTOR CONTROL FILE <br /> 06-EHD PERMIT FACILITY-see Linked PROGRAM FACILITY FILE 19-ENFORCEMENT CASE-Transferred to WELL PROGRAM FILE <br /> 07-REFERRED TO OTHER AGENCY 28-FOODBORNE ILLNESS-Unconfirmed <br /> 08-UNABLE TO VERIFY 29-FOODBORNE ILLNESS-Confirmed <br /> 09-FOODBORNE ILLNESS 50-LEAD HAZ EVALUATION REQUIRED(1) <br /> 10-SUBSTANDARD PROPERTY-SEE HOUSING ABATEMENT FILE 51 -LEAD HAZ WORK PLAN SUBMITTED(2) Complaint HEtoty <br /> I 11-Multiple Complaints-SEE ACTIVE CASE# 52-LEAD HAZ ABATEMENT IN PROGRESS(3) Attached But N U t <br /> 12-ENFORCEMENT CASE-Transferred to LIQUID WASTE FILE 53-LEAD HAZ VISUAL INSPECT SATISFACTORY(4) Scanned <br /> 13-ENFORCEMENT CASE-Transferred to SOLID WASTE FILE 54-LEAD HAZ DUST EVALUATION SATISFACTORY(5) <br /> COMPLMNT DESK <br /> COPY <br /> 5104.rpt <br />