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Complaint Investigation Form Report#:5104 <br /> COMPLAINT ID: C00037014 Site Location: 8023 WEST LN Account ID: AR0004856 <br /> Received by: EED090753 MARTINEZ Received Date: 9/19/2013 Print Date: 9/19/2013 8:43.55AM <br /> Assigned To: EE0005362 WIESEMAN Assigned Date: 9/19/2013 <br /> J <br /> ProyrarrVElement Code:1600-FOOD PROGRAM <br /> Complainant: :TASHA RANDLE Nome Phone 209-951-2404 <br /> Address Work Phone :510-677-5897 <br /> -Mail Address <br /> Nature of complain t: <br /> ON 9118(C)BOUGHT A STRAWBERRY SODA WHEN SHE WENT IN DRIVE THRU,AFTER DRINKING 314 OF IT. IT TASTED FUNNY&WHEN SHE <br /> LOOKED INSIDE SHE FOUND BLACK DEBRIS IN IT. <br /> Complaint Mode: P Complaint Mode Codes A-Agency Referral B-Bd of Supervisors 1 City Council C-Counter F-Fax <br /> E-Code Enforcement M-Mail I Correspondence O-Other EH Unit P-Phone <br /> I-Internet!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 RP/DBA CHURCH'S CHICKEN <br /> STOCKTON,CA 95210 RP Address 1501 CORPORATE WAY <br /> Cross Street WEST LAME SACRAMENTO,CA 95831 <br /> I11 Mailing Address: 1501 CORPORATE WAY Billing Address 1501 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 003-BESTOLARIDES Location Code 01-STOCKTON <br /> APN 08818007 <br /> Date Abated at-2-v1_ Inspector ID#: <br /> Send Referral to Referral Letter Sent by <br /> Referral Address Date: <br /> Complaint Status Code:o& <br /> i <br /> Circle appropriate Status Code <br /> 12-DA Referred Complaint-See Violation Tracking Form <br /> k 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 /> DA-ENFORCEMENT ACTION INITIATED 52-LEAD Abatement Regired-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 /> 08-UNABLE TO VERIFY CL-Case Closed <br /> 10-POSTED SUBSTANDARD/UNSECURED-See Housing File <br /> 11-Multiple Complaints-SEE ACTIVE CASE# <br /> E <br /> r� <br /> +� 5104.rp1 <br /> { <br />