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BOARD OF HEALTH
CITY HALL
COMPLAINT RECORD
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Complainant: O Ui 3 \ACTU
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Address: I' C\L . (�, A'ly`
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NATURE OF COMPLAINT:
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Location: i---53
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Owner: µAZSv.nti of , -A.EE
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Taken by:
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INSPECTOR'S REPORT:
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Total#of Inspections. Orders Issued?:
Date of Final Inspection: Notice of Compliance?:
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Inspector Signature
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