Environmental Health Services
Reviewed Date 01/07/2020
Page 1 of 1
Environmental Health
Services
PO Box 70
Sunshine Victoria 3020
T 9249 4000
F 9249 4351
W brimbank.vic.gov.au
I/We
of
Phone:
Mobile:
being the purchaser(s)/solicitor of the premises situated at:
do hereby request for an inspection of the premises by an Environmental Health Officer so that a current status
report can be obtained.
Signature:
Date:
Proposed settlement date : ___________________________________
Preferred Report Delivery method:
Consent to disclose information
I/We
of
Phone:
Mobile:
being the proprietor(s) of the premises situated at:
do hereby consent to the disclosure of all information relating to the above-mentioned premises as a result of
the said inspection, whether such information or such documents were obtained from me/us or otherwise.
Signature:
Date:
Privacy statement
The personal information requested on this form is being collected by Council for the purpose of meeting its legal obligations under the Food Act 1984, the Public Health
Health & Wellbeing Act 2008 and associated or related legislation. The information will be kept confidential and identifying information will not be disclosed to any person
for any other purpose. You may access your own information by contacting Council’s Environmental Health Services on 9249 4000.
Request for inspection
Environmental Health Services
Tax Invoice
Office use only
Fee (within 10 working days):
$292.00
Fee (within 5 working days):
$
468.00
Debtor#:
