Environmental Health Complaint / Referral Form

The form below may be used to submit or refer a complaint of a Sanitary Code violation to the Environmental Health Division. Alternatively, you may print a paper copy of the form and send it by mail or fax.

Environmental Health Complaint / Referral Form (paper copy)

Blocks marked with an asterix (*) are required. Please note that a place name (if a public place), street address, or tax map number is also required. Tax map numbers can be found using the Cattaraugus County Real Property Parcel Viewer.

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Complainant / Reported by

Name of the person filing the complaint

Address of the person filing the complaint

Address

City/Town

State/Province

ZIP/Postal Code

Telephone

Telephone number of the person filing the complaint

Email (optional)

Confirm email

Withhold Name

Check yes if you would like to remain anonymous during the investigation of your complaint

Yes

Nature of the Complaint / Referral

Describe the nature of your complaint or referral. Please include as much detail as possible. You may be contacted for more information if necessary.

Name (if a Public Place)

If complaint is concerning a public place, enter the name of the place. Leave blank if complaint is concerning a private property.

Address where the complaint is located (If known)

Address where complaint is located

City/Town where complaint is located

Tax Map Number

Tax map number of the parcel where the complaint is located. (these may be found using the Cattaraugus County Interactive Parcel Viewer linked at the top of this page)

Owner / Occupant of the Property (if known)

Owner or occupant of the property

Environmental Health Complaint / Referral Form

Health Department

Contact Information