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o'~ ~"-IF9 DATE RECEIVED <br />„,,~,~`yo Office Use Only <br />~~+~ CITY OF SAN LEANDRO <br />y~ R~ <br />Y~616 <br />ADA /SECTION 504 GRIEVANCE FORM <br />LAST NAME MIDDLE INITIAL FIRST NAME <br />STREET ADDRESS CITY STATE ZIP CODE <br />TELEPHONE NUMBER 2 TELEPHONE NUMBER <br />E-MAIL ADDRESS <br />Please provide a complete description of the specific issue(s) you believe are <br />inconsistent with the Americans with Disabilities Act/Section 504 (use additional pages <br />as necessary and provide documentation supporting the allegation, if appropriate). <br />Please provide a specific location(s) of the ADA/504 issue(s) prompting this grievance. <br />Date when the ADA/504 non-compliance occurred/was noted. <br />Page 1 of 2 <br />