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Environmental Health Complaint Referral Form

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Tell us about yourself:

Chautauqua County Health Department will not disclose your name and contact information, but this information is required to submit a complaint. Incomplete or fictitious submissions will not be investigated.

Name

Telephone Number

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Email (Optional)

Tell us about your complaint:

Nature of Complaint

Location of complaint (Business Name/Property Owner)

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

3/2014