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b,y i..ARf,)LD " , Nage <br /> 01 a" 01 COMPLAINT INVESTIGATION REPORT <br /> MPLAINT # = C0009120 program/Element : 1600 <br /> Ta(ce by 3304 ARMSTRONG Date' 10/02157 Assigned to : 0794 MATHEW Date: 10/02/97 <br /> Haro COPY PT:rted• <br /> F�.G i l i tv Name: DE . V INC_I S...DEL,ICATESSI~.N Fac I D: 00251.5 <br /> BILL to inventoried FACILITY: <br /> Location: 455.x. _.,, N.....PEFt1H.INC.......#::'3. (.Must have FACILITY ID#) <br /> i QrYlpldl.ili nt : MAR'IA"NNE..._,HER,NANDE.L..... <br /> .......................,..Nome Phone: 2©9-468--6440 <br /> Address ' ..,Work Phone : <br /> FACILITY LOCATION/Property Info — <br /> Loc Codes : .0 . <br /> GBA or Name : DE.._.�J.INCIS,._DELICATESSEN ............_...._. - ..... <br /> Address= 4555 ._N_. PERSHI,NG 21....... .... BOS Dist : 002. <br /> _.._. <br /> City- STnc"_KT01,1 g5207 APN tt = <br /> Phone : 209--957-2750 <br /> BILLING RESPONSIBLE PARTY or OWNER Info — <br /> Name = DE_. V .NCIS REDELI.CAT_ESSEN Nome Phone: <br /> Address : 4555IJ...__ .RSHING .._ <br /> ._ AVE,.„#,21 _......... „_.._. Work Phone: 209--957-2750 <br /> Cit,- 5TOr�.KTON CA 95207 <br /> ........... <br /> _...._-........... _....... <br /> 9atLre of ComDla,nt: <br /> ATE SALAD WITH BLUE CHEESE DRESSING BECAME ILL TWO HOURS LATER . <br /> COMPLAINT Info — <br /> � f <br /> COMPLAINT MODE: P PRONE � <br /> A-Agency Refers; S-BD OF SupeTvisoTs/City Ccouncil C-Counter M-Mail/Correspondence <br /> O-Other EH Unit P-Phone <br /> COMPLAINT STATUS: <br /> C'1-Fie.a ,bated 02-Office Abated 03-NAI Sent 04-Notice to Abate Issued 05-Enforce ACT Initiated <br /> 3b-'Tansfer to Premise Fi;e 07-Retsr to Other Agency 06-Not Valid 09-Foodborne Illness <br /> Send Referral Letter to: <br /> Address: <br /> Retr- r al LL�tt :r Sent by , �v Gate : . <br /> Circle approeriate Unit # if complaint in another PROGRAM jurisdiction, Have Complaint Record and P/E undated <br /> �arwarde, to UNIT: Q II III IV for Investigation <br />