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COVPLAINT INVF.STI[.ATION FORM <br />Date Complaint <br />Received Al <br />Received From <br />Address <br />Tele No. <br />NATUEE OF CC',:PLAI NT <br />/ S 1/iFc <br />/t x. 1 /1�.0 ✓S i �t q V, <br />Date or Inspection <br />zl%5� <br />VIOLATIONS NOTED <br />QA(/S� <br />Owner/7enant Name <br />Address /, ,C�.� , ',4 <br />ACTIC•'? TAKE?! <br />RFVU—KS <br />Fol lox -up date <br />Inspectors Signature <br />I <br />Y�Y <br />wa <br />