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**IMPORTANT**

Select the "Submit" button only once.

If you are not re-directed to the "Thank You" screen after clicking submit, please verify you have completed all the required fields. Errors will be shown to the right of the required field.

TYPE OF CONCERN:

Select all violation categories that apply:

Food Borne Illness
Food Facility - Rodent, Fly, Cockroach, Sanitation
Illegal Food Vendor
Sewage or Wastewater Discharge
Trash or Debris Accumulation
Swimming Pool / Spa Problem
Body Art Facility Problem
Waste Tire Disposal
Dust
Odor
Smoke
Other

Brief Description of Complaint:

COMPLAINT INFORMATION - Address and City are required.

Name of Parcel Owner (If Known):

Address:

APN:

City:

Zip Code:

Phone Number (If Known):

Is this Residential Property?:

Is this Commercial Property?:

YOUR INFORMATION

NOTE: The following information is required in order to submit a complaint. (Your personal information will be kept confidential)

First Name:

Last Name:

Mailing Address:

City:

ZIP Code:

Email Address:

Daytime Phone #:

SIGNATURE:

When Submitting an on-line form, typing your name below is equivalent to a signature.

Signature:

Date:

**IMPORTANT**

Select the "Submit" button only once. If you are not re-directed to the "Thank You" screen after clicking submit, please verify you have completed all the required fields. Errors will be shown to the right of the required field.

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