File a Complaint: Environmental Health

Please complete the form below to the best of your ability. Try to provide the most accurate information possible.
Any personal information you provide is confidential and cannot be released to any outside organization or the public.
Only violations or problems in Rockland County will be addressed.
 
Date problem occurred or began:ex.(00-00-00)
 
1. Tell us about yourself: 

 Your Name:
 Address:
 City / State / Zip Code:
 Phone Number: ex.(000-000-0000)

 Alternate Number: ex.(000-000-0000)

 E-Mail Address:

You wish to be contacted about this complaint.
 
2. Tell us about the problem:
 Name of Facility (if applicable):
 Name of the Owner or Tenant:
 Address:
 City / State / Zip Code:
 Phone  Number: ex.(000-000-0000)
 Nature of the Complaint: (Please select at least one)  
  Little Heat / No Heat  
  Poor Living Conditions  
  No Smoke Detector / No CO Detector  
  Improper Storage of Garbage  
  Insects / Rodents  
  No Water / No Hot Water  
  Low Water Pressure  
  Brown Water / Discolored Water  
  Swimming Pool Problem  
  Air Quality Problem  
  Sewage Overflow  
  Mosquito Problems  
  Day Camp Problem  
  Gas Station Problem  
  Smoking in Public  
  Bad Food Served at a Restaurant  
  Illness from Food Served at a Restaurant or Food Service Establishment
  Problem with Food Served at a Restaurant or Food Service Establishment
  Other (please describe)
 Please explain the details of the problem:
 
3. Tell us about the owner of the property where the problem took place:
 Name of Establishment / Facility:
 Name of the Owner or Manager:
 Address:
 City / State / Zip Code:
 Phone  Number: ex.(000-000-0000)