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SHORT-TERM COMPLAINT 111_3 <br /> Complaint # <br /> �.j <br /> Taken By 'r71 Facility ID# <br /> AllZV '�Y Program <br /> Date <br /> prcmise <br /> / 33 5 . <br /> DBA Phone ( 1 <br /> owner/Operator City State _ZIP <br /> Address Phone ( ----�— <br /> Complainant's Name <br /> City Zip <br /> Address <br /> Nature of Complaint <br />