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uaze run i ]/15/` 6 SAN JVAUUIN 1,;UUv I Y HUbLIU HtAL I H tijtKVII: K,SCM $5N4 <br /> Run by CAROLINE Page # 1 <br /> Copy # 01 of 01 COMPLAINT INVESTIGATION REPORT <br /> '"'MM MMM <br /> ""MMMMM <br /> COMPLAINT # CO001O46 Program/Element : 4000 <br /> arwr by : 2I1.5 CAyuL NE NAaCINcNii Date; 11/1,A3 �.wgre0 to 0369 ALAN DIEDERMANN Date: 11/15113 <br /> Facility Name: YE OLDS HOOSIER INN Fac ID: 001652 <br /> 5HL tf, invento'ied, FAINIE Y: <br /> Location: 1537 N WILSON WAY ,Must Nave F,4CII716; <br /> <br /> <br /> FACILITY LOCATION/Property Info — <br /> DBA or Name: Ye Olde Hoosier Inn Loc Code 01 <br /> Address: 1537 N Wilson BOS Dist <br /> City: Stockton 95205 APN # <br /> Phone: 209-463-0271 <br /> BILLING RESPONSIBLE PARTY or OWNER Info — <br /> Name: Home Phone: <br /> Address: 1537 N Wilson Work Phone: <br /> City: Stockton CA 95205 <br /> Nature of Complaint; <br /> ate lunch on 11/13/93—found a roach in soda—establishment did not chg <br /> for lunch—please call complaintant after completing inspect.w/results <br /> COMPLAINT Info — <br /> COULAINi MODE: P NRR_ <br /> A-Agency Rvs rra; BALE F1 Cc ounci! C-Counter U-9a1l/C.orresp0P0e Ice <br /> 0-01ther EM Ur�it 0-,ons <br /> i�ONPtA.tNi SiA.iUS; <br /> E-Field Attsd u2-Office Abated 03-0I Ser' ld-NoticR to Ahais issued OE-Erfcrce AN it tinted <br /> 06-Transfer to Premise File • U-Refer to Other Agency Cr-Not Valid 0:-Foodborre illness <br /> Circle appropriate Jnit i if canpla',rt `n anotaer PROGvAN i:risd'ction, ave Ca�pla`nt „scc'tl and �iE updated <br /> Forwded to 11Niii ii iII IV for irvcstiaatlon <br /> } <br />