(complete as much as possible)I hereby request an investigation of the public health hazard or unsafe property condition described below:*Location (be specific):*Physical Address of Property:Name:* Address* Street Address City State / Province / Region ZIP / Postal Code Phone*Mailing Address of Owner:Name* First Last Address* Street Address City State / Province / Region ZIP / Postal Code Phone*How long has the condition existed?*Have you reported this condition to the person responsible?* Yes No Has complainant been notified?* Yes No Has this condition been reported to another agency?** Yes No *IF yes, name of agency reported to: Extermination required* Yes No Additional relevant details:If you wish to include photos exhibiting the condition of the property, please attach them here.Accepted file types: jpg, jpeg, gif, png, pdf, tif, Max. file size: 64 MB.CAPTCHA
