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Date run: 07/28/9 SAN J'OAQUIN COUNTY PUBLIC HEAL T H !6LHV . - KePOTL PageROM 2 <br /> Run by CAROL D, <br /> Copy # : 01 of 01 COMPLAINT INVESTIGATION REPORT <br /> COMPLAINT # 00010720 Prn ram/Element 1698 /°9C16/5ZY <br /> Taken by : 0794 MATHEW Date: 01121198 Assigned to 34 HLIN Date: 07/28/98 <br /> Hard copy Printed: 6-.6 1 <br /> Facility Name: KMART......._...::....... N Fac ID : 0.6594 <br /> BILL to inventoried FACILITY: <br /> Location: 2180 E MARIPOSA RD (Must have FACILITY ID#) <br /> Complainant: R .NT_ERIA---R,OSEL_,IE . . ..................._._.. ....._Home Phone : 209-466-4563 <br /> Address : Work Phone : <br /> a <br /> FACILITY LOCATION/Property Info — <br /> DESA or Name: KMART/MIDWAY. ._OF FUN _.._........._..................................................... . ... .. Loc Code : Q.L. <br /> Address: 2,180....._E....MAR_I_PAS.......................................__...- _......_..-............................._._.........................._.......... ... .._. .B0S Dist : <br /> City: STOCKTON 95205 APN # : <br /> Phone: 916-381-4612 <br /> BILLING RESPONSIBLE PARTY or OWNER Info — <br /> Name: MIDWAY._n .._._F N.......................................................................... _........._Home Phone : 916381-4612 <br /> Address: 5480.... N HWY......99............._........................_....._................ -._Wor k Phone: <br /> .................... <br /> City = STOCKTON CA 95212 <br /> Nature of Complaint: <br /> ATE BEEF AND BEAN BURRITO FROM REFERENCED FACILITY ON 071-18--98 . BECAME <br /> ILL 07--19-98 AND WAS CONFIRMED SHIQ%LLA AT SAN JOAQUIN HOSPITAL . <br /> COMPLAINT Info -- <br /> COMPLAINT MODE: P PHONE <br /> A-Agency Referral A-80 OF Supervisors/City Ccouncil C-Counter M-Mail/Correspondence <br /> 0-Other EH Unit P-Phone <br /> COMPLAINT STATUS: � . <br /> Abated 0.2-0#fi.ce Abated 03-NAI Sent 04-Notice to Abate Issued 05-Enforce ACT Initiated <br /> 06- ansfer to Premise File 07-Refer to Other Agency 08-Not Valid 09-Foodborne Illness <br /> Send Referral Letter to: <br /> Address: <br /> Referral Letter Sent by : w Date: — <br /> Circle appropriate Unit # if complaint in another PROGRAM jurisdiction, Have Complaint Record and P/E updated <br /> Forwarded to UNIT: II III IV for Investigation <br />