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Q0F%7 5tate,CA Age: &� SOXIM IV. SEAFOOD INVESTIGATION SECTION vibrio species' For each seafood ingestion investigated,please complete as many of the following questions as possible. (Include additional pages section IV If more then one seafood typo was ingestod and Investigated.) 1. Typo of seafood(e.g„Clams): Data Mo, pay Yr- Time nHour Min cflnaumed: consumed: V ® ,n w c nsumed: 11464•S'64 tlm,-14W P469.61 II+EA901 (14911 1199$•45121 If patient a multiple aeafood6 in the 7 days before onset of illness,please note why this seafood was investlpaled(e,y„consumed raw,Impltaaled In outbreak invesUgatlon): 2. Mow was thisflah oraeafood prepared? (isls) ?<-aw m ©Baked w Q Boiled W [l Broiled fe r Frled iso Q Steamed 4u Q Unk.19l ❑Other is(speoify), 0s1a1sss: Ys;*(i) No 0-I Unk f0 If YES•specify s. was seafood imported from another country? 11s31) exporting coon"H known: n sa2.155q Ycs O) NP(2) Unk 1% 4. Was this fish or shellfish harvested by the patient or a friend of the patient? In � (if YES,go to question 12.) 5, Where was this seafood obtalned?0ss6)(Chock oaa) l s.Name of restaurant'oyster bar,or food store: ITel.1 ❑oyster bar or restaurant ns ❑seafood market 141 L-I Unk.(9) ❑Truck or roadside vendor m ❑Other tai Address: /� ootl score as (s `ry)' 1(557.1 c7-T L� s-E�4 F( L)4 7, lr oysters,clams,or mussels were eaten,howwere they OletrIbOOd to the retail outlet?05911 JaShellstoek(sold in fhb shelll iii"In Shucked it E]Unk.Ie) 0 Other cel (speoify): n592•u1o) 5. Date restaurant or food Mo, Day Yr, S.Was this restaurant or Yes ds No m urns tat outlat received seafood: ` food outlet Inapectad as 11617) ® Fili�11671-16141 part of this investigation? ❑ ❑ 14.Are shipping tags available Y g 11. Shippers who handled suspected seafood: (please include certification numbers if on tags) from the suspect iota Pole) ILII tp sal A- %3--1 3-:5 ILA El 0 (Attach copies if available) bc - i,q T - 12.Source(e)of seafood: 10.Karvest site: pate:�Mo, Cay Yr. Statua: Approved Ill Conditional t5) \` / r��w • .(1619,)Qrj�I OI� 2 0640-16451 at"6t®Prohibited Irl a Oth1➢r IBI(specify); Ip47-16001 �7:�LS� ® ❑Approved m ❑Condito vs it 181(s C S g 0467.1 04se•1494: ilc94i Prohibited l21 ❑other pecify): nees•,7w Noe Measlard 14.Physical rnAracterlsOm of harvest area as Result Mo. Day Yr, close as possible to harvest data: ❑F ill Maxlrnum ambient tamp. .......................(,)16.171 ❑ t21 m m PM1725) t17�HF j1} Surtwe water temp. ................... C M ��m 1,729 v341 es m Salinny m 11737.17421 Tatar rainfall (inehes In prey.5 days) ....D74s•1744t �J L.L-J m][I]1174s.17501 Fecal coliform count .............—..............11761.1770= =m 0:1Ir756.17611 (A t ch copy of CAllform data) Yea P) N0121 121 16.Was there evidence of improper storage,crosscentamination,or holding temperature at any point? 0 I oras If YES,specil'y deficiencies: Person completing section IV: Date: Mo. Day Yr. �! �\ 5R]qi�K�;170.176M TltletAgency: TaL: 201-(-( --t u COC,Pryai Gaanv,ce oKear,IfCQ C'GRvn Reid,M9 674,A,6pn1l.6AbeJ3',ATN:7RA(oe2e•UBCMI.CDC r2.77(pl.Rev.A*280T1 GCG 52,79(Zwi,RCv,Brt807(Papp 4 of+) (GOC Adobe Aw6el7.o Flo W4 V�rtivn,124Q7) Received Time Aug. 31. 2012 9: 39AM N0, 1030