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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SHORT TERM COMPLAINT FORM <br /> DATE: „ 2 y -I INSPECTOR(LASTNAME): NAG COMPLAINT NO: <br /> TAKEN BY(LAST NAME).- �,{I/j/vt 5 PROGRAM: rb FACILITY ID NO: <br /> DISTRICT: LOCATION: APN: CROSS STREET: <br /> PREMISE ADDRESS: ST# STREET NAME CITY Zip <br /> DBA: a r� <br /> OWNERIOPERATOR: <br /> ADDRESSITELEPHONE: <br /> COMPLAINANT NAME: <br /> ADDRESSITELEPHONE: <br /> COMPLAINT: <br /> f <br /> (A)Agency Referral (S)Board of Supervisors (C)Counter (E)Code Enforcement (F)Fax(1)lnternet/Email (M)MaiVCorrespondence (0)Other/EHD Unit (P)Phone <br /> EHD 48-03 <br /> 519/22 <br />