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2. Submitter Information
4. Submitted By
5. Agency
7. Office Number
8. Mobile Number
10. Email Address
12. Violation Description
14. Location of Offense
15. Nature of Violation & Timeline
17. Complaints Against This Location
19. Property Owner (If Known)
21. Name
22. Phone Number
24. If the referral is submitted by a regulatory agency:
26. Date of Last Inspection
    Date of Last Inspection
28. Findings of Last Inspection
30. Any Other Information
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32. 1. Receive an email copy of this form.
33. Email address

    This field is not part of the form submission.

34. Submit

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