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Complaint Investigation Form <br />COMPLAINT ID: C00046210 Site Location: 2720 COUNTRY CLUB BLVD <br />Receivedby: EE0000040 JIMENEZ <br />Assigned To: EE0000753 NG <br />Proaram/Element Code:1600 - FOOD PROGRAM <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br />Report #: 5104 <br />4/5/2018 4:53:3611M <br />FHIS COMPLAINT WAS FOUND IN FILING CABINET AND ALLEGES "PURCHASED THREE TO FOUR CHICKENS ON 1-12-91 AND BARBECUED <br />FHEM LATER IN THE DAY. 3 CHILDREN BECAME ILL (VOMITING, HEADACHES, DIARRHEA) AND WERE ALL TAKEN TO THE EMERGENCY <br />ROOM FOR TREATMENT." ORIGINAL CO # 910038 DATED 01/15/1991 (GIVING ITAN ENVISION COMPLAINT # TO HAVE IN DATABASE <br />:OR FUTURE REFERENCE.) <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-Sherifrs Office <br />PROPERTY INFORMATION <br />Property Name: <br />Site Location 2720 COUNTRY CLUB <br />STOCKTON. CA 95204 <br />Cross Street <br />Phone <br />District 003 - BESTOLARIDES, STEVE <br />APN 12118016 <br />PROPERTY OWNER INFORMATION <br />Responsible Party or Property Owner: SAFEWAY SUPERMARKE'T'S <br />RP/DBA SAFEWAY SUPERMARKETS <br />RPAddress 2720 COUNTRY CLUB BLVD <br />STOCKTON, CA 95204 <br />Billing Address 2720 COUNTRY CLUB BLVD <br />Home Phone :209-464-0439 <br />Work Phone : 209-464-0439 <br />Location Code 01 -STOCKTON <br />Date Abated � . CD . N Inspector ID #: r -1)Q <br />Send Referral to l U 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 <br />02 - Office Response Only <br />06 - Violations Cited - see Linked PROGRAM FACILITY FILE <br />07 - Refferred to Other Agency <br />08 - Unable to Verify Alleged Complaint <br />10 - POSTED SUBSTANDARD/UNSECURED - See Housing File <br />11 - Multiple Complaints - SEE ACTIVE CASE # <br />12 - DA Referred Complaint -See Program Enforcement Action Form <br />15 -ACTIVE HOUSING CASE - NEW COMPLAINT see ACTIVE CASE # <br />28 - Alleged FBI - No Major Violations Identified <br />29 - Alleged FBI - Major Violations Identified <br />50 - LEAD Assessment Performed -No Abatement Required <br />52 - LEAD Abatement Regired-See Program Record File <br />b97 Disaster Planning and Response <br />99 NSPECIFIED-Old Complaint -No Original Found <br />MN - EHD Monitoring Status <br />PD - Permit Issued -Pending Well Installation <br />RS - Resolved - New Well Installed <br />31 -Tank pumped <br />S2 - Hooked up to public sewer <br />S3 - Septic system repaired <br />i <br />omp aint Reviewed by: ate' Updated by: Dat <br />5104. rpt <br />