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{ a kA Complaint Investigation Form Report 9: 5104 <br /> COMPLAINT ID: C00040458 Site Location: 1138 S MAIN ST Account ID. AR0009289 <br /> Received by: EE0000028 ALI Received Date: 10!112015 Print Date: 10/1/2015 11:12:01AM <br /> Assigned 7o: EE0004589 LINHARES Assigned Date: 10/1/2015 <br /> Programeflkment Code•1600-FOOD PROGRAM <br /> Complainant: :DIANNA GUALDERAMA Home Phone 209-681-8245 <br /> Address Work Phone , <br /> Mail Address <br /> Nature of complaint: <br /> COMPLAINANT WENT TO DAIRY QUEEN FOR DESSERT WITH FAMILY ON 09129/2015.COMPLAINANT SPOTTED A COCKROACH ON THE <br /> COUNTER AND IT WENT UNDERNEATH THE REGISTER.COMPLAINANT'S SPOUSE PICKED UP THE REGISTER AND WHOLE FAMILY OF <br /> COCKROACHES WERE FOUND.PLEASE CALL COMPLAINANT WITH FINDINGS, <br /> Complaint Mode: P Complaint Mode Codes A-Agency Referral B-Bd of Supervisors 1 City Council C-Counter F-Fax <br /> E-Code Enforcement M-Mail 1 Correspdndence O-Other EH Unit P-Phone <br /> 1-Internet!Email S-Sheriffs Office, <br /> FACILITY INFORMATION OWNER INFORMATION <br /> Facility:FA0000814-DAIRY QUEEN Owner: OW0005549-DUAN,RAYMOND <br /> Site Location 1138 S MAIN ST RP/DBA DAIRY QUEEN r <br /> MANTECA,CA 95336 RP Address 4919 BAY VIEW CER <br /> Cross Street MAIN STOCKTON,CA 95219-2031 <br /> Mailing Address: 4919 BAY VIEW CIR Billing Address 4919 BAY VIEW CIR <br /> STOCKTON,CA 95219-2031 STOCKTON,CA 95219-2031 <br /> Home Phone :209-473-1210 <br /> Phone :209-473-1929 Work Phone :209473-1929 <br /> District 005-ELLIOTT,BOB Location Code <br /> APN 22105025 <br /> Date Abated �O ` Inspector ID#: <br /> Send Referral to Referral Letter Sent by <br /> Referral Address Date. <br /> Complaint Status Code: <br /> � <br /> A. <br /> Circle appropriate Status Code <br /> 15-ACTIVE HOUSING CASE-NEW COMPLAINT see ACTIVE CASE# <br /> 01-FIELD ABATED 28-FOODBORNE ILLNESS-No Major Violations identified <br /> 02.OFFICE ABATED 29-FOODBORNE ILLNESS-Major Violations Identified <br /> 03-NAI SENT 50-LEAD Assessment'Performed-No Abatement Required <br /> 04-NOTICE TO ABATE ISSUED 52-LEAD Abatement Reqired-See Program Record File <br /> 3, <br /> 05-DA-ENFORCEMENT ACTION INITIATED 97-Disaster Planning and Response <br /> 06-EHD FACILITY-see Linked PROGRAM FACILITY FILE 99-UNSPECIFIED-Ofd Complaint-No Original Found <br /> 07-REFERRED TO OTHER AGENCY CL-Case Closed <br /> 08-UNABLE TO VERIFY MN-EMD Monitoring Status <br /> PD-Permit Issued-Pending Well Installation <br /> 10-POSTED SUBSTANDARD/UNSECURED-See Housing File RS-Resolved-New Well Installed <br /> 11-Multiple Complaints-SEE ACTIVE CASE u <br /> 12-DA Referred Complaint-See Violation Tracking Form <br /> omp aint Reviewed by: ate: pate y: ate: <br /> 5104 rpt <br />