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2. First Name*
3. Last Name*
5. Email*
6. Requestor's Daytime Phone*
   Example: 317 823-2332
10. Nearest Major Intersection*
12. Location of Complaint
14. Describe the Problem
16. Destination
    Requests will be sent to the Government of Hamilton County Health Department. For questions or concerns, please email Environmental Health Specialist or call 317-776-8500.
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18. 1. Receive an email copy of this form.
19. Email address

    This field is not part of the form submission.

20. Submit

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