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" 0.7[� a— Complaint Investigation Form Report: 5104 <br /> COMPLAINT ID: C00043560 Site Location: 4555 N PERSHING AVE Accouri AR0004994 <br /> Receivedby: EE0000012 MARTORELLA Received Date: 6/1/2017 Print Date: 6/1/2017 8:19:36AM <br /> Assigned To: EE0003361 FLOHRSCHUTZ Assigned Date: 6/1/2017 <br /> Prooram/Element Code:1600-FOOD PROGRAM <br /> Complainant: :MARIA Home Phone : 209-361-3969 <br /> Address Work Phone <br /> -Mail Address lopezmary20glcloud.com <br /> Nature of complaint: <br /> COMPLAINT SENT IN VIA EMAIL AS WELL.COMPLAINANT ATE THE"SEVEN MARES"DISH AND HORCHATA FROM THE LOCATION.CLAIMS IT <br /> DIDN'T APPEAR TO BE FULLY COOKED.EXPERIENCED VOMITING AND CRAMPS.NO MEDICAL ATTENTION SOUGHT.CLAIMS THIS IS THE <br /> SECOND TIME THEY GOT ILL FROM EATING AT THE FACILITY. REQUESTING FOLLOW-UP FROM INSPECTOR. <br /> Complaint Mode: p Complaint Mode Codes A-Agency Referral B-Bd of Supervisors/City Council C-Counter F-Fax <br /> E-Cade Enforcement M-Mail/Correspondence O-Other EH Unit P-Phone <br /> I-Internet/Email S-Sheriffs Office <br /> ---------------------------------------------- <br /> PROPERTY INFORMATION OWNER INFORMATION <br /> Facility:FA0004641-CAROLINAILOS TRES PRIMOS Owner: OW0015183-ANGULO,SERGIO&VALLE,JUAN <br /> Site Location 4555 N PERSHING AVE STE I8C RPIDBA 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-MILLER,KATHERINE Location Code 01-STOCKTON <br /> APN 11017001 <br /> Date Abated 6 —161, —J') Inspector lD <br /> Referral Letter Sent b <br /> Send Referral to Y <br /> Referral Address Date: <br /> Complaint Status Code: qO <br /> Circle appropriate Status Code <br /> /15^-�ACTIVE HOUSING CASE-NEW COMPLAINT see ACTIVE CASE# <br /> 01-Field Response-Violations Cited and Corrected (2s-Alleged FBI-No Major Violations Identified <br /> 02-Office Response Only .29--Alleged FBI-Major Violations Identified <br /> 50-LEAD Assessment Performed-No Abatement Required <br /> 52-LEAD Abatement Regired-See Program Record File <br /> 97-Disaster Planning and Response <br /> 06-Violations Cited-see Linked PROGRAM FACILITY FILE 99-UNSPECIFIED-Old Complaint-No Original Found <br /> 07-Refferred to Other Agency <br /> 08-Unable to Verify Alleged Complaint MN-EHD Monitoring Status <br /> PD-Permit Issued-Pending Well Installation <br /> 10-POSTED SUBSTANDARD/UNSECURED-See Housing File RS-Resolved-New Well Installed <br /> 11-Multiple Complaints-SEE ACTIVE CASE If <br /> 12-DA Referred Complaint-See Violation Tracking Form <br /> omp amt ewew y: v/ ate: pate y: ate' <br /> lad J <br /> 5104.rpt <br />