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<br /> _OMPLAINT # COO13O21 pr,� rasr:'Fl �inpnt 2545
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<br /> i:rc ;nvy Printed:
<br /> = i1ity Name : Fac TD : tf
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<br /> �ocation= tIOODI�iORC}IM�I<:I�ti_,.......`" n (Must have FRCI,_T!
<br /> (imp iainant. :
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<br /> FACILITY LOCATION/Property Info —
<br /> D B A or Name: ..... ....�..�. .. .. � d-1
<br /> Address= WO {. .. - G�is .
<br /> City : MANTEC.A APN tt =
<br /> Phone ,
<br /> BILLING RESPONSIBLE PARTY or OWNER Info —
<br /> Nam-�: __ Home Phone
<br /> Address, Work Phone ,
<br /> City = \.
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<br /> COMPLAINT Info —
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<br /> "-'-p%y Reta.ra:
<br /> �'-Cth=.r CFI ant ;;.7.e
<br /> iald Abated IV'2-vffuat24' 03-1441 Sen`. 04-Noti:e tc Ahata 13sued 0.5-Enforce ACT initiate
<br /> tr '�i.lig? Fi+, �'-�.?;:, :o D i,e' Agency O�-yot Vlli' Ci9-Foo&wn: Illn?'i9
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<br /> Send Referral Letter to: / WAYA _/
<br /> Address: , C11 _ a� C
<br /> ,.: fe rra..l Letter Sent by: Date :
<br /> Circe appropriate Unit d if complaint in another PROGRAM urisdi_ti r,, Have Complaint Record and PIE updated
<br /> Forwarded to UNIT: I 1110,
<br /> 1V for Investigation
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