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Complaint Investigation Form Report#:5104 <br /> COMPLAINT ID: 000040243 Site Location: 8023 WEST LN Account ID: ARD004856 <br /> Receivedby: EE0000025 SEDRA Received Date: 8/24/2015 Pnnt Date: 8/24/2015 4.40551'M <br /> Assigner/To EE0001084 RAMIREZ Assigned Date: 8/24/2015 <br /> Pmgram/Element Code 1600-FOOD PROGRAM <br /> Complainant: : <br /> <br /> -Mail Address <br /> Natutoofcomplain t: kr-dit4 RfWd OVJ941)c lSmf� �ill7✓ P'.-Chkir . <br /> ON SUNDAY,8/23/2015 AT 3:00 PM,8 PEOPLE AXE CHICKEN TO GO.A 84 YEAR OLD MALE,64 YEAR OLD MALE,62 YEAR OLD FEMALE,61 <br /> YEAR OLD FEMALE,59 YEAR OLD MALE,40 YEAR OLD MALE,13 YEAR OLD FEMALE AND A 6 YEAR OLD MALE ALL BECAME ILL WITH <br /> SYMPTOMS OF VOMITING,DIARRHEA AND FEVER AFTER EATING THE CHICKEN.THE 6 YEAR OLD AND 61 YEAR OLD RECEIVED MEDICAL <br /> ATTENTION <br /> Complaint Mode. P Complaint Mode Codes A-Agency Referral B-Bd of Supervisors/Cay Council C-Counter F-Fax <br /> E-Code Enforcement M-Mail/Correspondence O-Other EH Unit P-Phone <br /> I-Intemet/Email S-Sherlfrs Office <br /> — - ---------- - - <br /> FACILITY INFORMATION OWNER INFORMATION <br /> Facility: FA0002725-CHURCHS CHICKEN 05773 Owner: OW0010559-H&R FOODS INC <br /> Site Location 8023 WEST LN RPrDBA CHURCH'S CHICKEN#5773 <br /> STOCKTON,CA 95210 RP Address 6248 PACIFIC AVE <br /> Cross Street HAMMER LN STOCKTON,CA 95207 <br /> Mailing Address: 6248 PACIFIC AVE Billing Address 6248 PACIFIC AVE <br /> STOCKTON,CA 95207 STOCKTON,CA 95207 <br /> Home Phone :661-703-7298 EXT: CELL <br /> Phone :209-475-1547 Work Phone :209-475-1547 EXT: BUSINESS <br /> Dishkt 003-BESTOLARIDES,STEVE Location Code 01-STOCKTON <br /> APN 08818007 + � a, .� <br /> Date Abated b l �] S Inspector ID#: #'-� yyl, <br /> — -----�------------ - - ------------------ - - - <br /> Send Referral to Referral Letter Sent by <br /> Referral Address Date: <br /> Complaint Status Code:aq <br /> Circle appropriate Status Code <br /> 15-ACTIVE HOUSING CASE-NEW COMPLAINT see ACTIVE CASE# <br /> 01-FIELD ABATED FOODBORNE ILLNESS-No Major Violations Identified <br /> 02-OFFICE ABATED 9 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 /> 05.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 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 /> ompaint Reviewed by: ate p ae y: Date, <br /> 1 � t <br /> 5104 Tt <br />