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Date of Complaint:
Time of Violation:
Location of Violation:
Name of Establishment:
Establishment Address:
Establishment Phone Number:
Type of Smoking Violation(s):
Smoking within 25 feet of an entrance, exit and wheel chair ramp.
Smoking being permitted in a no smoking area.
“No Smoking” signs are not posted.
Ashtrays present in non smoking area and/or within 25 of an entrance, exit, or wheel chair ramp.
Smoking infiltrating neighboring property.
Other (please explain below)
Your Name:
Your E-Mail:

For further assistance contact 832.393.5750.