State Form - 50014 - Idem Compliant Form Page 2
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1
2Indiana Department of Environmental Management
IDEM Complaint Form
State Form 50014 (R4 / 6-09)
PART C: POLLUTION ACTIVITY DETAILS
10. 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)
11. Please provide the date(s) and duration of the activity.
(e.g. 6/12/99-present; 4 hours in the morning)
12. Please describe the location of this pollution activity.
(e.g. in the back of the building; southeast of the property parallel
to SR 400 East; in the parts washing room)
13. Please provide us with driving directions to the site of the activity.
(e.g. take I-65 south to exit 49, take US 50 west to
Brownstown, take SR 135 south to Vallonia, the site is located 1 mile south of Vallonia on the left side of SR 135)
14. Complaint history
Have the allegations in this complaint been previously reported to any other agencies, officials, or persons?
Yes*
No
* If Yes, then please indicate to whom and when your complaint was reported:
15. How are you aware of and/or affected by the activity? (Example: My house is five yards from their property line
and I can see the damaged containers; I am currently employed there)
16. Additional comments
Thank you for helping to protect our environment!
Page 2 of 2
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