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SAN JOAQUIN COUNTY <br /> ENVIROINNIENTAL HEALTH DEPARTMENT <br /> SHORT TERM COINIPL.AENT FORM <br /> DATE: INSPECTOR (LASTNAME): 0 COMPLAINT NO: <br /> TAKEN BY (LASTNANIE): IMA AW PROGRAM: � � FACILITY ID NO: <br /> DISTRICT: LOCATION: APN: CROSS STREET: <br /> SITE ADDRESS: STREET# 6�O STREET NAMECIT( ZIP `)E— <br /> DBA: I�T's `-f ,,h�n O l op te-3 <br /> OWNER/OPERATOR: uruM - r) N o 9- s' _ C <br /> ADDRESS/TELEPHONE: -44() iE� Cwgje- r ,SQy)_ rna,�d{ �Q CA q?�Og <br /> COMPLAINANT NAME: nose <br /> ADDRESS/TELEPHONE: <br /> COMPLAINT: C <br /> ,-bra�zQ.fc C c w�o �-e- <br /> (A)Agency Referral (B)Board of Supervisors (C)Counter (E)Code Enforcement (F)Fax(I)lntemet/Email (M)?vlail/Correspondence (0)Other/EHD Unit (P)Phone <br />