2. Bismarck-Burleigh Public Health Environmental Health
   500 E Front Avenue * Bismarck, ND 58504 * Phone: (701) 355-3400 * Fax: (701) 221-6883 * Email: bbph@bismarcknd.gov
4. Date and Time
   Date and Time

   Date and Time
6. Location of the Complaint
   Be VERY specific if you do not know the address.
8. Complaint Description
   Describe the complaint.
10. Environmental Health Response
    Describe the best way for Environmental Health staff to view the complaint.
12. Upload Files
    Use this field to upload files or documents.
14. Reporting Party's Name
    If you wish to remain anonymous, DO NOT submit this information.
16. Reporting Party's Address
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18. Reporting Party's Phone
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20. Reporting Party's Email
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22. 1. Receive an email copy of this form.
23. Email address

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24. Submit Submit and Print

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