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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SHORT TERM COMPLAl T FORM <br /> DATE: - INSPECTOR (LAST NAME): Q C COMPLAINT NO:'- S�� <br /> TAKEN BY(LASTNAME): PROGRAM: a c FACILITY ID NO: <br /> DISTRICT:('O LOCATION: APN:yn,�?w -ao CROSS STREET: <br /> SITE ADDRESS: STREET# Tj STREET NAME —C 1/A'� ��TY L�� 1- ,qt ZIP 75 � <br /> DBA: ' ,*7 <br /> OWNER/OPERATOR: f 1 . �© <br /> ADDRESS/TELEPHONE: <br /> COMPLAINANT NAME: <br /> ADDRESS/TELEPHONE: <br /> COMPLAINT: 7 y 5 ? e S C <br /> G <br /> (A)Agency Referr((B) oard of Supervisors )Counter (E)Code Enforcement (F)Fax(n Intemet/Email (M)Mail/Correspondence (0)Other/EHD Unit (P)Phone <br /> tvn nv n <br />