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................................................................................ ....... ............................................................................................... ................................................................................................ .... ................................................... <br /> 1, <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SHORT TERM COMPLAINT FORM <br /> DATE: [a INSPECTOR (L,ASTNAME): U COMPLAINT NO: 357 <br /> TAKEN BY(LAST NAME): f�tA-eq--I KE7 PROGRAM: ((OC?-b FACILITY ID NO: j -7S-r7 <br /> DISTRICT: a LOCATION: APN: c�Z3 3 6 30-5-J1 CROSS STREET: <br /> PREMISE ADDRESS: ST# 3` D STREET NAMELO Cir-�� TY h ZIP <br /> �u i it i t � i i..�.�r+w ■ <br /> DBA: <br /> OWNERIOPERATOR: <br /> ADDRESSITELEPHONE: <br /> COMPLAINANT NAME: <br /> ADDRESS/TELEPHONE: <br /> COMPLAINT: Zp c-) <br /> L -cs1— <br /> (A)Agency Referral (B)Board of Supervisors (C)Counter (E)Code Enforcement (F)Fax(I)Intemet/Email (M)Mail/Correspondence (0)Other/EHD Unit Phone <br /> EHD 48-03 <br /> 519!12 <br />