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Boiler Complaint Form
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Steps
1.
Step One
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2.
Section I - Complainant
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3.
Section II – Complaint
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4.
Section III - Briefly Describe Your Complaint
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Step One
Fire Prevention Division-Boiler Safety Unit
State law requires all public buildings to provide basic life safety found in the Boiler Safety Code.
Complaint Record
1. Please type or print clearly in dark ink
2. Complete Section I, II & III below in order for complaint to be processed.
3. Return or forward completed form to Kansas State Fire Marshal
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Section I - Complainant
Name
*
Email Address
Address
*
City
*
State
*
Zip Code
*
County
Phone Number
*
Business Number
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Section II – Complaint
Public facility you are complaining about
*
Street Address
*
City/Town
*
Kansas Zip Code
*
County
*
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Section III - Briefly Describe Your Complaint
Description
I Agree
*
I agree that this signature is binding and I agree to all of the information I supplied
Complainant E-Signature
*
Date
*
Date
Received By:
Jessica Dunderdale
Date
Violation
Violates A
Violates B
Violates C
Approved By:
Date
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