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W° � Complaint Investigation Form Report#: 5104 <br /> COMPLAINT ID: C00041865 Site Location: 8023 WEST LN Amount ID: AR0004856 <br /> Receivedby: EE0000007 MORELLI Received Date: 7/12/2016 Print Date: 7/12/201611:30:33AM <br /> Assigned To: EE0001084 RAMIREZ Assigned Date: 7/12/2016 <br /> Prooram/Element Code:1600-FOOD PROGRAM <br /> Complainant: : <br /> <br /> <br /> Nature of complaint: <br /> COMPLAINANT ALLEGES SITE VISIT ON 7/7/2016,PURCHASED CHICKEN MEAL,THE CHICKEN HAD PLASTIC COKED INTO IT. RETURNED TO <br /> SITE AND SPOKE WITH THE MANAGER.COMPLAINANT ALLEGES THAT THEY BECAME ILL WITH SYMPTOMS OF VOMITING AND AN UPSET <br /> STOMACH. PLEASE CALL COMPLAINANT WITH FINDINGS. <br /> Complaint Mode. P Complaint Made Codes A-Agency Referral B-Bd of Supervisors/City Council C-Counter F-Fax <br /> E-Code Enforcement M-Mail/Correspondence O-Other EH Unit P-Phone <br /> I-Intemet/Email S-Sheritrs Office <br /> ----------------- -- ------------------------------- <br /> PROPERTY <br /> — _---_—__--__ -------------------------- ---- <br /> PROPERTY INFORMATION OWNER INFORMATION <br /> Facility:FA0002725-CHURCHS CHICKEN 05773 Owner OW0010559-H&R FOODS INC <br /> Site Location 8023 WEST LN RP/DBA CHURCH'S CHICKEN#5773 <br /> STOCKTON,CA 95210 RP Address 6248 PACIFIC AVE <br /> Cross Street 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 :209475-1547 Work Phone ;209-475-1547 EXT: BUSINESS <br /> District 003-BESTOLARIDES,STEVE Location Code <br /> APN 08818007 `1 <br /> Date Abated 'I <br /> 1 1 1�'k / Inspector to#: (, t y� <br /> Send Referral to {_.{ Y Referral Letter Sent by <br /> Referral Address Date: <br /> Complaint Status Code..-U j <br /> Circle appropriate Status Code <br /> 15-ACTIVE HOUSING CASE-NEW COMPLAINT see ACTIVE CASE# <br /> 01-Field Response-Violations Cited and Corrected 28-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 Reqired-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 /> !!-O nable 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# <br /> 12-DA Referred Complaint-See Violation Tracking Form <br /> F <br /> ompaint Reviewed by: Date'. p ate y: <br /> 5104 rpt b <br />