State Form - 50014 - Idem Compliant Form
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1
2Indiana Dept. of Environmental Management
IDEM COMPLAINT FORM
Attn: Complaint Coordinator
State Form 50014 (R4 / 6-09)
100 North Senate Avenue
INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT
MC 50-03 Room N 1313
Indianapolis, IN 46204-2251
NOTE:
Use this form to submit 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
Reset Form
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: PERSONAL 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
Please leave this section blank if you want to remain anonymous
requested.
.
1. Name
(first, last)
2. Street address (number and street)
City
County
State
ZIP code
3. Telephone number*
Home (
)
-
Work (
)
-
Mobile: (
)
-
*Please list only those phone numbers that IDEM may use to contact you.
4. E-mail address
5. Date sent to IDEM
(mm/dd/yyyy)
PART B: POLLUTION ACTIVITY
► Who do you think is responsible for the activity?
6. Owner/company name
7. Street address (number and street)
City
County
State
ZIP code
8. Telephone number
(
)
-
9. Nature of complaint (Check all that apply):
Air (Examples - fugitive dust, open burning, opacity, vehicle tampering)
Solid Waste (Examples - mismanagement of animal manure, open dumping of garbage, open dumping of tires, illegal discharge from a
septage hauler, open dumping of asbestos)
Hazardous Waste (Examples - problems involving used oil, damaged/rusted /abandoned drums)
Drinking Water (Examples – poor smelling, cloudy)
Wastewater (Examples - basement backup, stream pollution, septic ponding, facility failure)
Auto Salvage Yards (Examples - contaminated runoff, used oil dumping, and other pollution associated with auto-salvage yards)
Other (Please note that your county health department may have ordinances addressing complaints concerning odor, open dumping,
residential septics, swimming pools, abandoned vehicles, noise, and nuisance related issues.)
(Continued on page 2)
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