State Form 50014 - Pollution Complaint Clearinghouse: Pollution Complaint Form - Indiana Department Of Environmental Management

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POLLUTION COMPLAINT CLEARINGHOUSE:
Indiana Dept. of Environmental Management
Pollution Complaint Form
Attn: Pam O'Rourke
100 N. Senate Avenue
State Form 50014 (R/01-01)
P.O. Box 6015
INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT
Indianapolis, IN 46206-6015
§
NOTE:
This form should be used to mail a written complaint about an
environmental pollution problem to IDEM. Please be sure to
provide as much information as possible to ensure that IDEM is
able to thoroughly investigate your complaint.
§
Please note that if you provide any personal information on this
form, IDEM must publicly disclose this information if requested.
If you wish for your name, address, or phone number to remain
anonymous, please leave those lines blank.
§
Spills and other emergencies should be reported immediately
to IDEM by telephone at 1-888-233-7745 (toll-free)
§
PART A: COMPLAINANT INFORMATION
?
Personal information that you provide in this section (Part A) may allow IDEM staff to provide you with customer
service complaint updates, however, the personal information will become public record and may be disclosed when
requested. Please leave this section blank if you want to remain anonymous.
Please check (3) one:
1.
Individual (e.g. concerned citizen)
Public Official
Anonymous
2. Name
(first, last):
3. Street address:
City:
County:
State:
Zip:
4. Telephone number:
Home: (
)
-
Work: (
)
-
5. Date sent to IDEM
(mm/dd/year):
PART B: POLLUTION ACTIVITY
?
Who do you think is responsible for the activity?
6. Owner/Company Name:
7. Street address:
City:
County:
State:
Zip:
8. Telephone number:
(
)
-
9. Please describe the pollution activity.
(Please be as specific as possible and include specific allegations, stream names,
road names, quantity and types of materials involved, and other supporting information you think would be helpful):
(Continued on page 2)
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