Complaint Form - Zoomerang Online Surveys

Complaint Form

Questions marked with an asterisk (*) are mandatory.


	Complaints can be reported over the phone at (714) 433-6000 or online using this form. Environmental Health Staff will respond to this form during office hours (8am to 5pm, Monday – Friday, excluding holidays). All information is confidential and is not given to the owner/property owner or any other third party. This form is to be used only for non-emergency complaints. If this is an emergency, please contact your local police, fire department, or hospital by calling 9-1-1. Your name, phone number, email, and address are kept confidential. If this is a food illness complaint, please provide your contact information in order for our Staff to effectively respond to your complaint.

Incident Date/Time

Type of incident


	General food safety

	Food illness

	Water quality (beach water, storm drain, sewage, etc.)

	Hazardous waste (illegal dumping, storage, spills, etc.)

	Public swimming pools

	Substandard housing conditions

	Other, please specify

Describe your complaint in detail (if applicable, include date(s) and time(s) of incident)


	Name and address/location of business associated with complaint

Facility name:

Facility address or location:

Facility phone number:

Your contact information (optional and confidential)
I understand that lack of contact information can hinder the follow-up of my complaint and that my contact information is kept confidential.

Name:
Phone number:
Email:
Street address:
City:
Zip code: