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2. 

3. ENVIRONMENTAL HEALTH COMPLAINT FORM

5. COMPLAINANT INFORMATION
7. Name*
8. Email Address
10. Address
12. City
13. State
14. Zip Code
16. Phone Number*
20. COMPLAINT DETAILS
22. CATEGORY*
    -- Select One --Septic or WastewaterFood ServiceHotel, Motel, B & B, Tourist HomeTattoo or Body PiercingPool, Spa, Other Water FeatureTrailer Court or CampgroundOther Public Health Concern
23. PROPERTY TYPE*
    -- Select One --BusinessPrivate Property/Residence
25. Name of Business or Property Owner
26. Phone Number
28. Address
30. City
31. State
32. Zip Code
34. COMPLAINT DESCRIPTION*

    Please provide specific information on the circumstances or conditions of concern.   Include dates, times, observations, or any other information that could assist us during investigation.  

36. FILE UPLOAD

    You may upload photos or videos related to the complaint.  

38. FOLLOW UP

    Would you like us to contact you upon completing the investigation? 

    1. Yes
    2. No
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40. 1. Receive an email copy of this form.
41. Email address

    This field is not part of the form submission.

42. Submit

* indicates a required field