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Date run: 03/21/97 SAN JOAQUZN COUNTY PUBLIC HEALTH SERVIC Report I5104 <br /> Page # 2 <br /> Run by Gfo <br /> Copy # » 01 of 01 COMPLAINT INVESTIGATION REPORT <br /> Program/Element : 1617 <br /> COMPLAINTC0007922, # = Assigned to : - Date: 03121/97 #�nr � <br /> Taken by : 9451 NARY OSULLIVAN Date: x3/21/97 1& <br /> Hard copy Printed: 03/21/97 Fac ID: 000833 <br /> Facility Name: LUCKY,.._._D,TSGQj&T,..CEN7.ER..,__M...K ...... .1_ BILL to inventoried FACILITY: <br /> (Must have FACILITY IDA) <br /> Location: 1.1.7.2...........N._...N�.�_N...__S . <br /> Home Phone: 209--823-6399 <br /> Complainant: KI.M.__HIJf;Y.................._......_..._..........._...... <br /> ._...:......_. <br /> Work Phone: <br /> Address: _ . ....................... <br /> FACILITY LOCATION/Property Info — <br /> Loc Code : 04. <br /> DESA or Name: LUCKY,....b.LSC9UNT.......CC"wN1_ER_.. MKT....._#_i_8........................._..._......_..._._........_..._._...__..._.....BOS Dist : 003. <br /> Address: ........._................._......,.............................. __.._. <br /> 1.1.72....._...._N.__M:A_I.N...__SL...........__......._..................._......... A P N # : <br /> City: MANT CA. 95336 <br /> Phone: 51.0-678-4200 <br /> BILLING RESPONSIBLE PARTY or OWNER Info — Home Phone' 510_678_4200 <br /> Name <br /> L L1 G K Y....._$T 0 R r=......_I_IV C..._....._._._....._........._............_...._................................_..._._........_.._. <br /> .Work Phone: <br /> Address". . ....._......._.................... <br /> 1701......_....NA R I.N R...._E3 L V...............__.....__.......__..._._......_........_._._.............. <br /> city : ShIN.._ LENDR.O. CA, 94577A <br /> Nature of Complaint: <br /> ON 3/20/97 BOUGHT DELI MEAT ATE IT THIS MORNING BECAME ILL. THIS AFTER <br /> NOON . THIS NOT THE FIRST TIME . <br /> COMPLAINT Info — <br /> COMPLAINT MODE: P,._,..,..,_PHONE <br /> A'-Agency Referral B-BD OF Supervisors/City CcoUncil C-Counter M-Mail/Correspondence <br /> 0-Other EH Unit P-Phone <br /> COMPLAINT STATUS: <br /> 41-Field Abated 02-Office Abated 03-NAI Sent 04- a e ss 05-Enforce ACT Initiated <br /> 06-Transfer to Premise File , 07-Refer to Other Agen y OB-Not Valid -foodborne Illness <br /> Send Referral Letter to. <br /> Address: <br /> Referral Letter Sent by: Date: <br /> Circle appropriate Unit # if complaint in another PROGRAM jurisdiction, Have Complaint Record and P/E updated <br /> Forwarded to UNIT: (i? II III IV for Investigation <br />