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Environmental Health or Retail Food Concern

Establishment Type
If other, please describe
Establishment Name
Establishment Address
City
State
Zip
Date Visited or Date Concern Observed
Date Visited or Date Concern Observed
Date Visited or Date Concern Observed
What is your concern?
Your Name (optional)
Please provide an email address or phone number if you would like a member of our team to follow up with you.
Your email (optional)
Your phone number (optional)
Additional Information or Notes

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Email address

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