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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALDEPARTMENT <br /> SHORT TERM COMPLAINT FORM <br /> DATE: INSPECTOR (uSTNAME): 1 COMPLAINT NO: <br /> TAKENY (usTNnME): I PROGRAM: G. FACILITY ID NO: <br /> DISTRICT: LOCATION: APN: CROSS STREET: <br /> PREMISE ADDRESS: ST# ST.NAME mC� / / cl r ZIP <br /> DBA: <br /> OWNER/OPERATOR: <br /> ADDRESS/TELEPHONE: <br /> COMPLAINANT NAME: <br /> ADDRESS/TELEPHONE: <br /> COMPLAINT: /U � <br /> (A) Agency Referral (B) Board of Supervisors (C) Counter (E) Code Enforcement (F) Fax (I) Internet/Email <br /> (M) Mail/Correspondence (0) Other EHD Unit (P) Phone (S) Sheriffs Office <br /> :M 68-03 <br /> 16116 <br />