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. K � <br /> " Complaint Investigation Form Report#:•5104 <br /> COMPLAINT i • C00035171 Site Location: 1230 W KETTLEMAN LN AccountlD: AR0014570 <br /> Receivedby: EE0009058 LOWE Received Date: 5/5/2012 Print Date: 7/5/2012 2:06:11 PM <br /> Assigned To: EE0005362 WIESEMAN Assigned Date: 7/5/2012 <br /> Program/Element Code:1600-FOOD PROGRAM <br /> Complainant: ;NORA Home Phone 209-585-9546 <br /> Address : Work Phone <br /> -Mail Address <br /> Nature of complaint: <br /> ON 7/5/2012 @ 10:15AM PURCHASED CHOCOLATE CHIP PANCAKES.AFTER EATING SOME TO THE PANCAKE NOTICED A COCK ROACH IN <br /> THE OTHER HALF. (C)SPOKE WITH ASSISTANT MANAGER SANDRA AND WAS GIVEN A REFUND FOR THE MEAL, <br /> Complaint Mode: P Complaint Mode Codes A-Agency Referral B-Bd of Supervisors l City Council C-Counter F-Fax <br /> E-Code Enforcement M-Mail 1 Correspondence O-Other EH Unit P-Phone <br /> I-Internet/Ernall S-Sheriff's Office <br /> FACILITY INFORMATION OWNER INFORMATION <br /> Facility:FA0003926-[HOP Owner: OW0006538-SEVENTEEN FORTY EIGHT CO,INC <br /> Site Location 1230 W KETTLEMAN LN RP/DBA lHop <br /> LODI,CA 95240 RP Address 25020 STANFORD AVE 170 <br /> Cross Street KETTLEMAN VALENCIA,CA 91355 <br /> Mailing Address: 1230 KETTLEMAN LN Billing Address 1230 KETTLEMAN LN <br /> LODI,CA 95240 LODI,CA 95240 <br /> Home Phone <br /> Phone :209-369-1361 EXT: 0 Work Phone <br /> District Location Code <br /> APN 06004001 <br /> Data Abated �G _ ' Inspector ID#: G <br /> Send Referral to Referral Letter lent by <br /> Referral Address Date: <br /> Complaint Status Code: <br /> Circle appropriate Status Code <br /> 12-DA Referred Complaint-See Violation Tracking Form <br /> 01-FIELD ABATED 15-ACTIVE HOUSING CASE-NEW COMPLAINT see ACTIVE CASE# <br /> 02-OFFICE ABATED 28-FOODBORNE ILLNESS-No Major Violations Identified <br /> 03-NAI SENT 29-FOODBORNE ILLNESS-Major Violations Identified <br /> 04-NOTICE TO ABATE ISSUED 50-LEAD Assessment Performed-No Abatement Required <br /> 05-DA-ENFORCEMENT ACTION INITIATED 52-LEAD Abatement Reqired-See Program Record Fife <br /> Cg:ND FACILITY-see Linked PROGRAM FACILITY FILE 97-Disaster Planning and Response <br /> 07-REFERRED TO OTHER AGENCY 99-UNSPECIFIED-Old Complaint-No Original Found <br /> 08-UNABLE TO VERIFY CL-Case Closed <br /> 10-POSTED SUBSTANDARDlUNSECURED-See Housing Fite <br /> 11-Multiple Complaints-SEE ACTIVE CASE# <br /> 5104,rpt <br />