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2. Establishment Type
   -- Select One --Restaurant or Mobile Food VendorGrocery Store or MarketChildcare Facilityother
3. If other, please describe
5. Establishment Name
7. Establishment Address
9. City
10. State
11. Zip
13. Date Visited or Date Concern Observed
    Date Visited or Date Concern Observed

    Date Visited or Date Concern Observed
14. What is your concern?
16. Your Name (optional)
    Please provide an email address or phone number if you would like a member of our team to follow up with you.
18. Your email (optional)
19. Your phone number (optional)
21. Additional Information or Notes
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23. 1. Receive an email copy of this form.
24. Email address

    This field is not part of the form submission.

25. Submit

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