Received by: ____________________________________ Date ______
Property Owner Verified As _________________________________
Concern forwarded to:
Administration ___
Buildings ___
Police ___
Maintenance ___
Flood Plain Coordinator ___
Outside agency, if so who (give contact information for follow-up) _________________________________
Follow-up action taken: (Use blank sheet of paper for further reporting or documentation and attach to this report.)
Case closed: Yes ___ No ___
By whom?____________________________________ Initials _____
Date ______
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