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SAN JOAQUIN COUNTY <br /> ENVIRONAIENTAL HEALTH DEPARTAIENT <br /> SHORT TERM COMPLAINT FORM <br /> DATE: INSPECTOR ID#: COMPLAINT NO: <br /> TAKEN BY(ID#): O PROGRAM: FACILITY ID NO: �--- <br /> DISTRICT: LOCA ION: APN: CROSS STREET: <br /> PREMISE ADDRESS: STREET# STREET NAME nn `, CITY ZIP <br /> DBA: c, Ve <br /> OWNER/OPERATOR: <br /> ADDRESS/TELEPHONE: <br /> COMPLAINANT NAME: <br /> ADDRESS/TELEPHONE: <br /> t <br /> COMPLAINT: ` 2� <br /> (A)Agency Referral (B)Board of Supervisors (C)Counter (E)Cade Enforeentent (F)Fax(1)InterneUEmail (Nt)Mail/Correspondence (0)01}lcr,FE14D Unit (P)Phone <br /> rr1n o3 <br /> 10/ s <br /> 6 <br />