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Date run : 10/25/99 N JOAQUIN COUNTY PUBLIC HEALTH SERVIC Report 15104 - <br /> Run by : DENORA Page #A 1 <br /> Copy #k : 01 of ON COMPLAINT INVESTIGATION REPORT <br /> MMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMM <br /> COMPLAINT #A : C0013170 Program/Element <br /> Taken by : I829 GAGA2A Date: IO/22/99 Assigned to : N-(rT—�,tRRC�E$CO Date: 10/22/99 <br /> Hard copy Printed: AE�F�2 �5 L'-to� <br /> Facility Name : L U t X X— $ 310 Fac ID : 000395 <br /> SILL to inventoried PACII,ITY: <br /> Location: 530 W LODI AVE Gust have FACILITY IDG) <br /> Complainant: PAT Home Phone : 209-369-8500 <br /> Address : Work Phone : <br /> FACILITY LOCATION/Property Info <br /> DBA or Name : LUCKY STORE #A310 Loc Code : 02 <br /> Address : 530 W LODI AVE BOS Dist : 004 <br /> City : LODI 95241 APN #A <br /> Phone : 209-339-7170 <br /> BILLING RESPONSIBLE PARTY or OWNER Info — <br /> Name : LUCKY STORE INC Home Phone : 510-678-4200 <br /> Address : 1701 MARINA BLVD Work Phone : 209-339-7170 <br /> city : SAN LEANDRO CA 94577 <br /> Nature of Complaint: <br /> BOUGHT FRIED CHICKEN AT DELI INSIDE STORE AND THE CHICKEN HAS WORMS IN <br /> IT <br /> COMPLAINT Info — <br /> COMPLAINT MODE: P PHONE <br /> A-Agency Referral S-ED OF Supervisors/City Ccouncil C-Counter M-Mail/Correspondence <br /> 0-Other <br /> ` e <br /> HH Unit P-Phon <br /> COMPLAINT STATUS: C)" <br /> 01-Field Abated 02-Office Abated 03-NAI Sent 04-Not;Ke- o Abate Issued 05-Enforce ACT Initiated <br /> 06-Transfer to Premise File 01-Refer to Other Agency 08- t Valid 09-Foodborne Illness <br /> Send Referral Letter to: <br /> Address : <br /> Referral Letter Sent by : Date : <br /> Circle appropriate Unit I i€ compla'nt in another PROGRAM jurisdiction, Have Complaint Record and P/E updated <br /> Forwarded to UNIT: I II III IV for Investigation <br /> A <br />