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Request for Housing Quality Standards Inspection
This form has been modified since it was saved. Please review all fields before submitting.
NON-PROFIT AGENCY INFORMATION
Contact Last Name
Contact First Name
Contact Phone Number
Funding Source (SHP, CHG, 2163, ESG)
HOUSING UNIT INFORMATION
Tax Parcel Number
Complex Name (if applicable)
On-Site Contact Name
On-Site Contact Phone
Number of children under the age of 6 residing in the unit
Please check the one that applies; comments may be added below:
Literally Homeless, unsheltered
Literally Homeless, sheltered
FOR PIERCE COUNTY COMMUNITY CONNECTIONS INTERNAL USE ONLY
___ Arnold Nufer
___ Rand Bullinger
Date of Referral
Date Unit Passed Inspection
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