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Environmental Health Complaint Form

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First Name*

Last Name*

Address

Phone Number*

City

State

Zip Code*

Type of Complaint*

	Rats
	Housing

	Mold
	Other

Complaint Location

Complaint Address*

Complaint City*

Complaint State*

Complaint Zip Code*

Description
(Please fully describe complaint
including date and time of occurrence.)*

* indicates required fields.

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