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......... ....................... ......................................................... ..................................................... ................... ......... ....... ....... ................................................................................................ .................................................. <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SHORT TERM COMPLAINT FORM <br /> DATE: Z� 1�INSPECTOR(.TNAME): Der COMPLAINT NO: <br /> TAKEN Y(UITNAME): e �e_s PROGRAM: FACILITY ID NO: <br /> DISTRICT: LOCATION: APN: CROSS STREET: <br /> PREMISE ADDRESS: ST# STREET NAME D y� CITY Zip <br /> DBA: <br /> OWNERIOPERATOR: <br /> ADDRESS/TELEPHONE: <br /> COMPLAINANT NAME: <br /> ADDRESSITELEPHONE: I <br /> COMPLAINT: ck;ty kA <br /> �SfJT�l f�� • / i� <br /> (A)Agency Referral (B)Board of Supervisors (C)Counter (E)Code Enforcement (F)Fax(I)Internet/Email (M)Mail/Correspondence (0)Other/EHD Unit (P)Phone <br /> EHD 48-03 <br /> 5/9112 <br />