Riverside County Tobacco Violation Form

Please fill out the form below to report a violation of a tobacco law. The information you provide will be automatically forwarded to the Tobacco Control Project in the Department of Public Health. Please use this form only if the violation took place in Riverside County.

Date and Time of Violation:

Date of Violation:
Time of Violation:	(include AM or PM)

Location of Violation:

*Name of business (required):
Street Address:
City:
Zip:
Phone Number:

Type of Business:  

- Select business type - Restaurant Bar Bowling Center Bingo Hall Pool Hall Theater School Office Grocery Store Auto repair Parking Garage Apartment Building Liquor Store Convenience Store Other

If other, describe below:

Description of Violation (check all that apply):

Customer smoking indoors	Employee/Owner smoking indoors
Employee failed to inform violator(s) to stop smoking	NO SMOKING signs missing at entrance
Store sold tobacco to an adult for a youth outside	Ashtray present in smokefree area
Store sold tobacco to a youth	Other (describe below)
Briefly describe the violation below:	Name of employee(s) involved and how are they involved?

Location within business where violation was observed:

- Select location within business -    Dining Room Stairwell Outdoor Dining Area Covered Outdoor Area Lobby Lounge Bathroom Kitchen Office Bar Other Not_Applicable

If other, describe below:

Smokefree Violation Reported By: (anonymous complaints are accepted)

Your name:
Phone number:	(day) (evening)
E-mail address:
Street address:
City:		State:		Zip: