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Complaint Investigation Form <br /> COMPLA T ID: C00033757 Site Location: 678 N WILSON WAY <br /> Received by: EE000178 Report#:5104 <br /> k�5i rtsd 8 CASTANEDA n�w,urn. AR0004645 <br /> ri) EE0006213 PEDRAZA Re°eivedDate. 6/30/2.11 <br /> Pi°°ram/E/ement CodeAssigned Date: <br /> 1600 6/30/2011 Phnt Dafe. <br /> - <br /> <br /> <br /> Adtlress <br /> <br /> <br /> <br /> [FROM <br /> )PURCHASED CANTALOUPE FROM FACILITYC) 6/S SE ON 6/17/11, (C)qTE SOME OF THE CANTALOUPE AND BECAME ILL WITH <br /> MITING AND UPSET STOMACH. ON 6/22/11,(C)WAS SEEN BY DOCTOR AND GIVEN MEDICATION. (C)STATED THAT JUST IN THE PAST <br /> O DAYS,SHE HAS STARTED TO FEEL BETTER AND DID NOTIFY THE MANAGEMENT OF THE FACILITY. —*(C)REQUESTS A CALL BACK <br /> INSPECTOR AFTER INSPECTION. <br /> Complaint Mode: p Complaint Mode Codes <br /> A-Agency Referral B-Bd of Supervisors/City Council C-Counter F-Fax <br /> E-Code Enforcement M-Mail/Correspondence O-Other EH Unit <br /> P-Phone <br /> ————_— _ _ ___——_——_—_I-Internet/Email — S_Sher frs Of6oe <br /> — <br /> FACILITY INFORMATION ----------------- <br /> OWNER INFORMATION <br /> Facility:FA0002463-FOOD 4 LESS* Owner: OW0001562-PAQ INC <br /> Site Location 678 N WILSON WAY RP/DBA <br /> STOCKTON,CA 95205 RP Address 8014 LOWER SACRAMENTO RD STE I <br /> Cross Street STOCKTON,CA 95210 <br /> Mailing Address: 17935 MURPHY PARKWAY Biffing Address 17935 MURPHY PARKWAY <br /> LATHROP,CA 95330 LATHROP,CA 95330 <br /> Home Phone :209.957.4917 <br /> Phone :209-9574917 Work Phone :209-858-0101 <br /> District 001 -VILLAPUDUA Location Code 01-STOCKTON <br /> APN 14129006 <br /> Date Abated q/r/t/ Inspedor (42l3 <br /> ---------------- _— <br /> Send Referral to Referral Letter Sent by <br /> Referral Address Date: <br /> Complaint Status Code: 491 <br /> Circle appropriate Status Code <br /> 01 IELD ABATED 29-FOODBORNE ILLNESS-Major Violations Identified <br /> 02-OFFICE ABATED 50-LEAD Assessment Performed-No Abatement Required <br /> 03-NAI SENT 52-LEAD Abatement Regifed-See Program Record File <br /> 04-NOTICE TO ABATE ISSUED 97-Disaster Planning and Response <br /> 05-DA-ENFORCEMENT ACTION INITIATED 99-UNSPECIFIED-Old Complaint-No Original Found <br /> 06-EHD FACILITY-see Linked PROGRAM FACILITY FILE CL-Case Closed <br /> 07-REFERRED TO OTHER AGENCY <br /> 08-UNABLE TO VERIFY <br /> 10-POSTED SUBSTANDARDAINSECURED-See Housing File <br /> 11-Multiple Complaints-SEE ACTIVE CASE# <br /> 12-DA Referred Complaint-See Violation Tracking Form <br /> 15-ACTIVE HOUSING CASE-NEW COMPLAINT see ACTIVE CASE# <br /> 28-FOODBORNE ILLNESS-No Major Violations Identified <br /> 51�rp1 <br />