2. Please provide a description, facility name (if applicable) and address of your Environmental Health concern (i.e. food facility, septic system, water well, landfill, pool/beach, mosquitoes, etc.)
4. Facility Name (if applicable)
6. Address (No & Street)
7. City
8. Zip Code
10. If you would like us to respond to you about your concern, please provide contact information below.
12. Your Name
13. Your Email Address
15. Your Phone Number
17. Photo Upload
    You have the option to upload a photo to depict your concern.
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19. 1. Receive an email copy of this form.
20. Email address

    This field is not part of the form submission.

21. Submit

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