Los Angeles Fire Department Smoking Complaint Form Complete this form to submit a complaint regard ing a potential violation for smoking in a smoke-free area. In the City of Los Angeles, smoking includes the use of an electronic smoking device (such as an e-cigarette). You may submit your complaint anonymously. If you wish to remain anonymous, please skip to Section 2. SECTION 7: First Name
Last Name
Your Phone Number (include area code)
Your Email Address
SECTION 2: Complaint Description Type of Violation*
0 Smoking a Tobacco Product (Cigarette, Pipe, Hookah pipe etc.) in a smokefree area 0 Using an Electronic Smoking Device (E-Cigarette, Vape pen, etc.) in a smokefree area Who was smoking or using an electronic smoking device in a smokefree area*
D Owner/Manager/Person(s) in charge D Employee/Worker(s) 0 Customer/Patron/Visitor(s) D Other Location Information: Name of Business Where Violation Observ
Major Cross Streets of Business
Address of Business
City
Zip Code
City
Zip Code