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Complaint Investigation Form Report# 5104 <br /> Cc'MPLAiNT ID: 0038902 Site Location: 4555 N PERSHING AVE STE 18C Account ID AR0004994 <br /> Receivedby: EE0003361 FLOHRSCHUTZ Received Date: 11/24/2014 Print Date: 11/24/2014 11:22:27AM <br /> Assigned To EE0003361 FLOHRSCHUTZ Assigned Date: 11/24/2014 <br /> Pro4ram/Element Code:1600-FOOD PROGRAM <br /> Complainant : LAURA LOPEZ Home Phone <br /> Address Work Phone <br /> -Mail Address aunty u,gmat.corn <br /> Nature of complaint: <br /> FACILITY RE-USING CHIPS. EMPLOYEE TOUCHING HORCHATA DISPENSOR WITH FINGERS. OLDER EMPLOYEE NOT WASHING HANDS <br /> BETWEEN TASKS, <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-Sheriffs Office <br /> FACILITY INFORMATION OWNER INFORMATION <br /> Facility:FA0004641-CAROLINA/LOS TRES PRIMOS Owner: OW0015183-ANGULO,SERGIO&VALLE,.JUAN <br /> Site Location 4555 N PERSHING AVE STE 18C RP/DBA CAROLINA/LOS TRES PRIMOS <br /> STOCKTON,CA 95207 RP Address 2406 HANNA BAY CT <br /> Cross Street STOCKTON,CA 95210 <br /> Mailing Address: 4555 N PERSHING AVE STE 18C Billing Address 2406 HANNA BAY CT <br /> STOCKTON,CA 95207 STOCKTON,CA 95210 <br /> Home Phone :209-951-3972 <br /> Phone :209-474-0386 Work Phone :209-474-0386 <br /> District 002-RUHSTALLER,LARRY Location Code <br /> APN 11017001 <br /> Date Abated 1'1-H—f l I Inspector ID#: F[b h <br /> Send Referral to '1 Referral Letter Sent by <br /> Referral Address Date: <br /> Complaint Status Code: 01(4L_ <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 SUBSTANDARD/UNSECURED-See Housing File <br /> 11-Multiple Complaints-SEE ACTIVE CASE# <br /> 12-DA Referred Complaint-See Violation Tracking Form <br /> 5104 rpt <br />