Texas Commission On Environmental Quality Landscape Irrigation General Complaint Form printable pdf download

Texas Commission On Environmental Quality Landscape Irrigation General Complaint Form

Texas Commission on Environmental Quality

Landscape Irrigation General Complaint Form

Please Print or Type. For more information, see reverse side.

COM PLAINT REGISTERED AGAINST (RESPONDENT):

Respondent’s Full Nam e_____________________________________________Hom e Phone___________________

Cell Phone________________________Business Phone ___________________________

Address ______________________________________________

City ___________________________ State _____________ZIP____________________ County

Business Nam e _________________________________________________________________________________

Business Address________________________________________________________________________________

City ___________________________ State ____ZIP_______ County

Lic. No.____________________

PERSON REGISTERING COM PLAINT (COM PLAINANT) -OR- CIRCLE: ANONYM OUS

Com plainant’s Nam e________________________________________________Hom e Phone ___________________

Cell Phone________________________Business Phone___________________________

Address________________________________________________

City ____________________________ State ______________ZIP_________________

Business Nam e ________________________________________ Lic No. if applicable_________________________

DETAILS OF YOUR COM PLAINT

DESCRIBE YOUR COMPLAINT IN SUFFICIENT DETAIL ANSW ERING THE FOLLOW ING QUESTIONS: W HO IS THE

IRRIGATOR? W HAT DATE AND TIME DID THIS INCIDENT OCCUR? W HERE DID THIS INCIDENT OCCUR? W HAT IS

THE PHYSICAL ADDRESS (STREET, CITY, COUNTY) W HERE THE IRRIGATION SYSTEM IS LOCATED?

ATTACH

PERTINENT COPIES OF DOCUMENTS SUCH AS CONTRACTS, PLANS, RECEIPTS, CORRESPONDENCE, PICTURES,

ETC. TO SUBSTANTIATE THE ALLEGATIONS. (Attach additional sheets where necessary.)

Have you talked with the Respondent about this com plaint?

Yes

If so, when:

Results:

By m y signature, the facts thus stated, are true to the best of m y knowledge and belief.

Signature:______________________________________________Date:____________________________________

Please note that you may be asked to sign an affidavit, testify in court, and/or certify what you have reported if the

investigation results in cited violations leading to an enforcement action.

This box for TCEQ staff use only. Date Received: __________ Incident No. ___________ Staff initials: ________

)

TCEQ-10380 (04-08-08

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Texas Commission On Environmental Quality Landscape Irrigation General Complaint Form