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Licensed Facility Complaint Form

Submitted by envhealth on Tue, 08/14/2007 - 21:20.

Licensed Facility Complaint Form

Date*

Name of Facility: *

Facility Location:

Description of Complaint: *

Complainant Name:

Complainant Address:

Complainant Phone Number:

Complainant e-mail:

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Malheur County | 251 "B" St. West | Vale, OR 97918

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