2. Date*
   Date
4. Your Name
5. Phone Number
7. Email Address
9. Type of Complaint

   1. Food Lodging & Institutions
   2. Onsite Water Protections
   3. Public Swimming Pools & Spas
   4. Body Art
   5. Other

   Select one
10. Owner or Manager Name
12. Enter type of complaint
14. Address for the Complaint*
16. Establishment Name, if applicable
18. Body Artist Name, if applicable
20. Complaint Details
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26. 1. Receive an email copy of this form.
27. Email address

    This field is not part of the form submission.

28. Submit Submit and Print

* indicates a required field