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A111M <br /> Complaint Investigation Form Report#:5104 <br /> COMPLAINT ID: C00051202 Site Location: 3201 W BENJAMIN HOLT DR Account ID: AR0038704 <br /> Received by: EE0001788 CASTANEDA Received Date: 11/14/2019 Print Date: 11/15/2019 4:11:00PM <br /> Assigned To., EE0006213 PEDRAZA Assigned Date: 11/15/2019 <br /> Program/Element Code 1600-FOOD PROGRAM <br /> Complainant: <br /> <br /> <br /> Nature of complaint: <br /> COMPLAINANT(35),HUSBAND(32)AND CHILD(2 1/2)ORDERED FOOD FROM FACILITY ON 11/13 AROUND 5-6PM AND BROUGHT FOOD <br /> HOME TO EAT. COMPLAINANT AND HUSBAND BECAME ILL AROUND 1-2 AM WITH VOMITING AND DIARRHEA. CHILD BECAME ILL WITH <br /> SAME SYMPTOMS AROUND 12:00 AM. COMPLAINANT AND CHILD ATE PEPPERONI PIZZAAND CHICKEN WINGS,HUSBAND ATE PIZZA, <br /> CHICKEN WINGS AND BREAD STICKS. ALL THREE STILL ILL AT THE TIME OF COMPLAINT. DID NOT SEE DR OR SPEAK WITH ANYONE AT <br /> FACILITY. CALL BACKAFTER INSPECTION. <br /> Complaint Mode: P Complaint Mode Codes A-Agency Referral B-Bd of Supervisors/City Council C-Counter F-Fax <br /> E-Code Enforcement M-Mail/Correspondence O-Other EH Unit P-Phone <br /> I-Internet/Email S-Sheriffs Office <br /> --------------------------------------------- -- -- - <br /> PROPERTY INFORMATION RESPONSIBLE PARTY INFORMATION <br /> Facility:FA0021343-EDDIE'S PIZZA CAFE RP DBA <br /> Site Location 3201 W BENJAMIN HOLT DR STE 121C RP mailing address <br /> STOCKTON,CA 95219 <br /> Cross Street HERNDON <br /> Mailing address PO BOX 6098 RP contact <br /> STOCKTON,CA 95206 RP contact phone <br /> Phone 209-951-4999 EXT: <br /> Owner: OW0021327-ESALOO,VICTOR <br /> DBA EDDIES PIZZA CAFE <br /> Owner address PO BOX 6098 <br /> STOCKTON,CA 95206 <br /> Billing Address PO BOX 6098 <br /> STOCKTON,CA 95206 <br /> Home Phone 209462-4762 <br /> Work Phone 408-309-2544 EXT: <br /> District 002-MILLER,KATHERINE Location Code 01 -STOCKTON <br /> APN 10017009 <br /> Date Abatedf I Inspector ID#: <br /> Send Referral to Referral Letter Sent by <br /> Referral Address Date: <br /> Complaint Status Code: <br /> Circle appropriate Status Code <br /> 01-Field Response-Violations Cited and Corrected 29-Alleged FBI-Major Violations Identified <br /> 02-Office Response Only 50-LEAD Assessment Performed-No Abatement Required <br /> 06-Violations Cited-see Linked PROGRAM FACILITY FILE 52-LEAD Abatement Reqired-See Program Record File <br /> 07-Referred to Other Agency 97-Disaster Planning and Response <br /> 08-Unable to Verify Alleged Complaint 99-UNSPECIFIED-Old Complaint-No Original Found <br /> 10-POSTED SUBSTANDARD/UNSECURED-See Housing File MN-EHD Monitoring Status <br /> 11-Multiple Complaints-SEE ACTIVE CASE# PD-Permit Issued-Pending Well Installation <br /> 12-DA Referred Complaint-See Program Enforcement Action Form RS-Resolved-New Well Installed <br /> 15-ACTIVE HOUSING CASE-NEW COMPLAINT see ACTIVE CASE# S1-Tank pumped <br /> 28-Alleged FBI-No Major Violations Identified S2-Hooked up to public sewer <br /> omp amt Reviewed br. qNate: p ate y: ate: <br /> 1110, <br /> 5104.rpt <br />