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2y <br /> -'s Complaint Investigation Form Report#:5104 <br /> COMPLAINT ID: C00036190 Site Location: 8023 WEST LN Account la• AR0004866 <br /> Received by: EE0090753 MARTINEZ Received Date: 3/27/2013 Print Date: 3/27/2013 2:34A6PM 1 <br /> Assigned To:. EE0005362 WIESEMAN Assigned Date: 3/27/2013 <br /> Proaram/Element Code"1600-FOOD PROGRAM <br /> Complainant: : <br /> <br /> <br /> Nature of complaint: <br /> ON 3126113 @ 17:25(5:25)(C)ORDERED&ATE A 2 PC CHICKEN MEAL(LEG,THIGH WITH MASHED POTATOES)&SMALL FRIES.LEG WAS <br /> VERY PINK INSIDE.ABOUT 15-30 MIN LATER,HE STARTED VOMITING&TODAY HAD DIARRHEA&SORE BODY <br /> Complaint Mode: P Complaint Mode Codes A-Agency Referral B-Bd of Supervisors I City Council C-Counter F-Fax <br /> E-Code Enforcement M-Mail I Correspondence O-Other EH Unit P-Phone <br /> R I-Internet I Email S-Sheriff's Office <br /> -------------------------- <br /> FACILITY INFORMATION OWNER INFORMATION <br /> Facility:FA0002725-CHURCHS CHICKEN Owner: OW0010559-CENTRAL VALLEY QSR <br /> Site Location 8023 WEST LN RPIDBA CHURCH'S CHICKEN <br /> STOCKTON,CA 95210 RP Address 1501 CORPORATE WAY <br /> i Cross Street WEST LANE SACRAMENTO,CA 95831 i <br /> Mailing Address: 1501 CORPORATE WAY Billing Address 150I CORPORATE WAY <br /> SACRAMENTO,CA 95831 SACRAMENTO,CA 95831 <br /> Home Phone :209-473-8184 <br /> Phone ;209475-1547 Work Phone ;209.475-1547 <br /> District Location Code <br /> APN <br /> Date Abated 'j--ZCa- t Inspector lD A 3 (p <br /> Send Referral to Referral Letter Sent by s?T! <br /> Referral Address Date: <br /> Complaint Status Code: tI <br /> Circle appropriate Status Code <br /> 12-DA Referred Complaint-See Violation Tracking Form <br /> 01-FIELD ABATED 15-ACTIVE HOUSING CASE-NEW COMPLAINT see ACTIVE CASE# <br /> 02-OFFICE ABATED 28-FOODBORNE ILLNESS-No Major Violations Identified <br /> 03-NAI SENT 29-FOODBORNE ILLNESS-Major Violations Identified <br /> 04-NOTICE TO ABATE ISSUED 50-LEAD Assessment Performed-No Abatement Required <br /> 05-DA-ENFORCEMENT ACTION INITIATED 52-LEAD Abatement Reqired-See Program Record File <br /> EHD FACILITY-see Linked PROGRAM FACILITY FILE 97-Disaster Planning and Response <br /> 07-REFERRED TO OTHER AGENCY 99-UNSPECIFIED-Old Complaint-No Original Found <br /> f 08-UNABLE TO VERIFY CL-Case Closed <br /> I <br /> 10-POSTED SUBSTANDARDIUNSECURED-See Housing File <br /> 11-Multiple Complaints-SEE ACTIVE CASE# <br /> k <br /> 1 <br /> 5ia4.rpr <br /> r <br />