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SAN JOAQUIN COUNTY <br /> ENV IRONNIENTAL HEALTR DEPARTMENT <br /> SfIORT TERM COMPLAINT FORM <br /> INSPECTOR IDlh f COMPLAINT NO: <br /> DATE: �� FACILITY ID NO: <br /> PROGRAM: <br /> TAKEN BY (ID#): <br /> APN: CROSS STREET: i <br /> DISTRICT: LOCATION: Zip <br /> PREMISE ADDRESS: STREET# <br /> STREET NAME CITY - <br /> DBA: �' rh <br /> OWNERIOPERATOR: E kG <br /> ADDRESSITELEPHONE: r 7 2 Q <br /> COMPLAINANT NAME: <br /> ADDRESSITELEPHONE: <br /> COMPLAINT: <br /> p) ency Referral (B)Board of Supervisors (C)Counter (E)Code Emiorcement (F)Fax.(1)Internet/Email (M)Nlail/Corrnpondence (0)Otheri4.i1I1)Unit (P)Phone <br /> L"-H 48-0J <br /> t ]5108 <br />