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r1• <br /> Complaint Investigation Form Report#:5104 <br /> COMPLAINT ID. C00029260 Site Location: 4555 N PERSHING AVE 16 Account ID: AR0004707 <br /> Received by: IE0002447 EVANS Received Date: 10/16/2008 Print Date:10/16/2008 4:55:03PM i <br /> Assigned To: EE0003474 VEGA Assigned Date: 10/1612008 <br /> Proram/Element Code;1600-FOOD PROGRAM <br /> Complainant: :MASAMI SITKIN Home Phone : 209473-8315 1 <br /> Address Work Phone <br /> Nature of corn faint: <br /> (C)PURCHASED SOME STEAMED POTATOES WITH THE ONLY INGREDIENTS BEING POTATOES, SUGAR,AND WATER. AFTER(C)ATE ONE <br /> OF THE POTATOES, HER MOUTH BURNED AS IF THE FOOD HAD PEPPER OR SOMETHING REALLY HOT ON IT. THE FOOD MADE(C)'S <br /> TONGUE NUMB,AND HER STOMACH HURT A LITTLE. (C)LEFT FOOD IN CAR FRO ABOUT 2 HOURS,AND FOOD HAD A VERY UNUSUAL <br /> SMELL. <br /> Complaint Mode: P Complaint Mode Codes A-Agency Referral 8-Bd of Supervisors I City Council C-Counter F-Fax � <br /> i <br /> E-Cade Enforcement M-Mail 1 Correspondence O-Other EH Unit P-Phone <br /> -------- ------------ ._ ------ <br /> FACILITY INFORMATION OWNER INFORMATION <br /> Facility:FA0002514-ASIAN SUPERMARKET Owner: OW0001919-UNG,ALICIA <br /> Site Location 4555 N PERSHING AVE 16 RP/DBA ASIAN SUPERMARKET <br /> STOCKTON,CA 95207 RPAddress 8667 MARINERS DR 67 <br /> Cross Street PERSHING STOCKTON,CA 95219 <br /> Mailing Address: 4555 N PERSHING#16 Billing Address 8667 MARINERS DR 467 <br /> STOCKTON,CA 95207 STOCKTON,CA 95219 <br /> Home Phone ;209-952-3508 <br /> Phone :209-957-3097 Work Phone :209-957-3097 <br /> District 002-RUHSTALLEIZ LARRY Location Code 01 -STOCKTON <br /> APN 11017001 <br /> Date Abated /0 — Z d� Inspector. 7 C( <br /> Send Referral to Referral Letter Sent by <br /> Referral Address ,, Date: <br /> Complaint Status Code:..i�_ <br /> Circle appropriate Status Code• <br /> 01-FIELD ABATED 14-ENFORCEMENT CASE-Transferred to ER FILE <br /> 02-OFFICE ABATED 15-ACTIVE HOUSING CASE-NEW COMPLAINT see ACTIVE CASE# <br /> 03-NRI SENT ;- 16.LETTER SENT TO TENANT <br /> 04-NOTICE TO ABATE ISSUED 17-15 DAY LETTER SENT <br /> 05-ENFORCEMENT ACTION INITIATED 18-ENFORCEMENT CASE-Transferred to VECTOR CONTROL FILE <br /> 0EHD PERMIT FACILITY-see Linked PROGRAM FACILITY FILE 19-ENFORCEMENT CASE-Transferred to WELL PROGRAM FILE <br /> 07-REFERRED TO OTHER AGENCY 20-ENFORCEMENT CASE-Transferred to UIC PROGRAM FILE <br /> 06-UNABLE TO VERIFY 28-FOODBORNE ILLNESS-Unconfirmed 1 No Major Violations <br /> 09-FOODBORNE ILLNESS 29-FOODBORNE ILLNESS-Major Violations Identified <br /> 10-SUBSTANDARD PROPERTY-SEE HOUSING ABATEMENT FILE 30-15 Day Letter Sent-Confirmed Complaint Complaint History <br /> 11-Multiple Complaints-SEE ACTIVE CASE# 31-15 Day Letter Sent-Alleged Complaint Attached But Not <br /> 12-ENFORCEMENT CASE-Transferred to LIQUID WASTE FILE 50--LEAD HAZ EVALUATION REQUIRED(1) <br /> Scanned <br /> 13-ENFORCEMENT CASE-Transferred to SOLID WASTE FILE 51-LEAD HAZ WORK PLAN SUBMITTED(2) <br /> I <br /> . I <br /> 5.1/rpt <br />