My complaint is on a ...
Fast Food Place
Mobil Unit (taco stand, etc.)
Ice Cream Truck
Name of establishment ...
Physical address of establishment ...
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Providing information in this dark gray box is optional
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Please provide a description of your complaint/comments (Please provide food safety specific description rather than monetary or behavioral issues): ...
Mobile Unit Information 1
If this complaint is on a mobile food unit/vehicle/illegal vendor, include a detailed description of the mobile unit/vehicle and the license plate number:
Mobile Unit Information 2
Days and time of day that the mobile unit/vehicle/illegal vendor was observed: