PDEQ Complaint Form

Complaint Form Their Information
Responsible Party Name:
Address:
City:
Zip:

Major Cross Streets:

Description: (of complaint)
Date & Time of Occurrence:

You may optionally include a picture with this form. To do so, browse to the location of the picture file so its location appears in the selection box. Leave the box blank otherwise. (To avoid errors, please limit picture size to 150KB or less - Thank You)
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Your Information (required if you want a reply - optional if you want to remain anonymous) (Be advised: all complaints become public record and are subject to dissemination upon request)
Complainant: (your name)		Email Address
Address:		Phone #1:
City:		Phone #2:
Zip:		Pager:

Complaint Form