Department of Health and Human Services
Bureau of Environmental Health | Noise Control Program
2525 Grand Avenue #220 | Long Beach, CA 90815
(562) 570-4132 | Hotline (562) 570-4126 | Fax (562) 570-4038
Rev: October 9, 2020
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1-1
NOISE COMPLAINT FORM
C
OMPLAINANT
I
NFORMATION
□ FIRST COMPLAINT □ SECOND COMPLAINT
Name: Phone:
ddress: Long Beach, CA Zip code:
Descri
be how this noise affects you:
N
OISE
S
OURCE
I
NFORMATION
Name:
Phone:
Address: Long Beach, CA Zip code:
Describe Noise:
Start Date: End Date
(if applicable):
Start Time: End Time:
Occurring Day(s):
□ Sun □ Mon □ Tues □ Wed □ Thurs □ Fri □ Sat
I hereby declare and certify under penalty of perjury that the information supplied on this noise complaint is true and correct to the best of
my knowledge.
Printed Name of Complainant Signature of Complainant
Date
FOR OFFICE USE ONLY
□ Approved □ Rejected Complaint # _CO000_______________
Received/by:
(Stamp) (Initial)
Complaint Restrictions / Reason for Rejection:
click to sign
signature
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click to sign
signature
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