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Physical Barrier Report Form: Woodside

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TOWN OF WOODSIDE 2955 WOODSIDE ROAD WOODSIDE, CA. 94062 (650)851-6790 REQUEST FOR SERVICE OR INVESTIGATION OF ACCESSIBILITY ISSUES Thank you for taking the time to bring this matter to our attention. Your request will be referred to the appropriate staff member for follow up. Please call Town Hall at the above telephone number if you have any other concerns or questions.   DATE: ____________________________________ TIME: ____________________ IN THE VICINITY OF: _________________________________________________ REQUEST: ___________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ YOUR NAME: _________________________________________________________ YOUR ADDRESS: ______________________________________________________ YOUR PHONE NUMBER: ________________________ RECEIVED BY: ________ ______________ PLEASE NOTIFY ________ NOTIFICATION NOT NECESSARY   FOR OFFICE USE ONLY REFFERED TO: _____________________________________________________ CC: ________________________________________________________________ ACTION TAKEN: ____________________________________________________ ____________________________________________________________________ RESPONSE DATE: _______________ COMPLETED BY: ___________________ (date work was done)_____________________ (work done by)_________________