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2. 
4. Date of Potential Violation:*
   Date of Potential Violation:
6. Detailed Description of Violation:*

   Please be sure to include address location name of owner and any other info if known.

8. We need to know how we may contact you just in case we need to clarify your request. Thank you!

   All reporting contacts remain confidential unless otherwise advised.

10. First Name*
11. Last Name*
13. Address1*
15. Address2
17. City*
18. State*
19. Zip
21. Email:*
23. If you want to provide any attachments for consideration:

    If you wish to provide a picture or document to backup this report, please do so here.

25. Additional Upload (if needed)
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27. 1. Receive an email copy of this form.
28. Email address

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29. Submit

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