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SHORT-TERM COMPLAINT <br /> Taken By r/ 5 Complaint # 656 1 <br /> Date l 9 Program �i` � Facility ID# <br /> Premise �5SG11• C Ss <br /> DGA <br /> Owner/Operator 7 Phone <br /> Address 6ifS G 1 c, _ �.,w City State _Zip <br /> �-�� ( <br /> Complainant' <br /> Address <br /> Nature of Complaint <br />