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. 1 <br /> Complaint Investigation Form Report#:5104 <br /> COMPLAINT ID: C00038345 Site Location: 4219 E WATERLOO RD Account ID. AR0002198 <br /> Receivedby: EE0009058 LOWE Received Date: 8/11/2014 Print Date: 8/11/2014 12:49-IIPM <br /> Assigned To: EE0001084 RAMIREZ Assigned Date: 8/11/2014 <br /> Program/Element Code:1600-FOOD PROGRAM <br /> Complainant :ANON Home Phone <br /> Address Work Phone <br /> -Mail Address <br /> Nature of complaint: <br /> 08/08/2014 @ 7 PM(C)ORDERED CHICKEN CORDON BLEU.(C)STATES THE SAUCE OR CHICKEN WAS SPOILED.EARLY MORNING <br /> 08/09/2014 SYMPTOMS INCLUDED STOMACH CRAMPS AND VOMITING. <br /> Complaint Mode. P Complaint Mode Codes A-Agency Referral B-Bd of Supervisors/City Counci I C-Counter F-Fax <br /> E-Code Enforcement M-Mail/Correspondence O-Other EH Unit P-Phone <br /> ]-Internet/Email S-Sheriffs Office <br /> FACILITY INFORMATION OWNER INFORMATION <br /> Facility:FA0002187-CLARION INN&SUITES Owner: OW0001699-WATERLOO ENTERPRISES INC <br /> Site Location 4219 E WATERLOO RD RP/DBA CLARION INN&SUITES <br /> STOCKTON,CA 95215 RP Address 4219 E WATERLOO RD <br /> Cross Street HWY 99 STOCKTON,CA 95215 <br /> Mailing Address: 4219 E WATERLOO RD Billing Address 4219 E WATERLOO RD <br /> STOCKTON,CA 95215 STOCKTON,CA 95215 <br /> Home Phone :209-981-8116 <br /> Phone :209-981-8116 Work Phone <br /> District 002-RUHSTALLER,LARRY Location Code <br /> APN 08710009 f <br /> Date Abated ' I + Inspector ID <br /> Send Referral to — Referral Letter Sent by <br /> Referral Address Date: <br /> Complaint Status Coder <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 Regired-See Program Record File <br /> DA-ENFORCEMENT ACTION INITIATED 97-Disaster Planning and Response <br /> 06 EHD FACILITY-see Linked PROGRAM FACILITY FILE 99-UNSPECIFIED-Old Complaint-No Original Found <br /> 07-REFERRED TO OTHER AGENCY CL-Case Cl osed <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 />