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-t <br /> Complaint Investigation Form <br /> Report#:510,4 <br /> .,COI�IIPLAI I=C0003=5620 Site Location: 1230 W KETTLEMAN LN Account ID: AR0014570 <br /> f Received by: EED009058 LOWE Received Date: 10/29/2012 <br /> Print Date: 10/29/2012 10:23:32AM <br /> Assigned To: EE0005362 WIESEMAN <br /> Assigned Date: 10/2912012 <br /> I <br /> Program/Element Code 1600-FOOD PROGRAM <br /> Complainant: ;ANON <br /> Nome Phone <br /> Address <br /> Work Phone <br /> Mai!Address <br /> Nature ofcofn Taint: <br /> ROACH INFESTATION.FOUND A COCK ROACHE&IN SYRUP ON THE TABLE. <br /> Complaint Made: p Complaint Mode Codes A-Agency Referral B-Bd of Supervisors/City Council C-Counter F-Fax <br /> I <br /> t E-Gude Enforcement M-Mail/Correspondence O-Other EH Unit P-Phone <br /> I' ——— ———`———— I-Internet I Email S-Sheriff's Office <br /> FACILITY INFORMATION OWNER INFORMATION — — — <br /> I Facility:FA0003926-IHOP Owner: OW0006538-SEVENTEEN FORTY EIGHT CO,INC <br /> Site Location 1230 W KETTLEMAN LN RP/DBA IHOP <br /> I <br /> LOD],CA 95240 RP Address 25020 STANFORD AVE 170 <br /> Cross Street KETTLEMAN VALENCIA,CA 91355 <br /> i Mailing Address' ]230 KETTLEMAN LN Billing Address 1230 K GTTLEMAN Lha <br /> LOD],CA 95240 LODI,CA 95240 <br /> Home Phone <br /> I <br /> Phone :209-369-1361 EXT: 0 Work Phone <br /> District Location Code <br /> APN <br /> Date Abated ! Inspector ID#., M Flo h r5c k,4,L+Z <br /> --- - ------------------------------------------------ - <br /> Send <br /> — ----- ------- -------------- — _Send Referral to Referral Letter Sent by <br /> Referral Address Date: <br /> Complaint Status Code: <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 /> 05-DA-ENFORCEMENT ACTION INITIATED 97-Disaster Planning and Response <br /> O6 EHD FACILITY-see Linked PROGRAM FACILITY FILE 99-UNSPECIFIED-Old Complaint-No Original Found <br /> 07-REFERRED TO OTHER AGENCY CL-Case Closed <br /> 08-UNABLE TO VERIFY <br /> 10-POSTED SUBSTANDARDIUNSECURED-See Housing File <br /> 11-Multiple Complaints-SEE ACTIVE CASE# <br /> 12-DA Referred Complaint-See Violation Tracking Form <br /> 4 <br /> II <br /> 5104-rpt {` <br /> 1 <br />