Complaint Intake Form

Nearest Marked Address or Intersection*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Type of Complaint*
Description of Complaint*
Your Contact Information (Optional)
Name
Phone Number

Area CodePhone Number
Cell Phone

Area CodePhone Number
E-mail
If you do not wish to enter the required fields then please contact the Environmental Health office at 336.570.6367.
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