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Premises address *

Name of current owner *

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I, being the being the current proprietor of the above named premises, do hereby request for: *

An inspection of the premises by an Environmental Health Officer in order that a current status report of the premises can be completed.

The disclosure to all persons of all information or publication of documents relating to the premises which may be revealed or obtained as a result of the said inspection, whether such information or such document was obtained from me or otherwise.

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