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M SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SHORT TERM COMPLAINT FORM_ <br /> DATE: S 40/5 INSPECTOR (LASTNAME): ��5.�/�7 COMPLAINT NO: -3 <br /> TAKEN BY(LAST NAME): bextr- PROGRAM: FACILITY ID NO: <br /> DISTRICT: LOCATION: APN: CROSS STREET: <br /> SITE ADDRESS: STREET# STREET NAME CITY ZIP <br /> DBA: <br /> OWNERIOPERATOR: <br /> ADDRESS/TELEPHONE: <br /> COMPLAINANT NAME: <br /> ADDRESSITELEPHONE; <br /> COMPLAINT: <br /> (A)Agency Referral (B)Board of Supervisors (C)Counter (E)Code Enforcement (F)Fax(I)Intemet/Email (M)Mail/Correspondence (0)Other/EHD Unit (P)Phone <br /> HHD 48-03 <br /> 4104/12 <br />