Free 50014.pdf - Indiana

POLLUTION COMPLAINT CLEARINGHOUSE: File a Pollution Complaint
State Form 50014 (R3 / 6-05) INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT

Indiana Dept. of Environmental Management Attn: Complaint Coordinator
100 North Senate Avenue MC 50-03 IGCN 1313 Indianapolis, IN 46204-2251 http://www.IN.gov/idem/pollutioncomplaints/

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 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 requested. Please leave this section blank if you want to remain anonymous. 1. Please select whether you are an...
Individual (e.g. concerned citizen) Public Official Anonymous

2. Name (first, last): 3. Street address: City: 4. Telephone number*:
Home: ( ) Work: ( ) Mobile: ( ) *Please list only those phone numbers that IDEM may use to contact you.

County:

State:

ZIP code:

5. E-mail address: 6. Date sent to IDEM (mm/dd/year): PART B: POLLUTION ACTIVITY Who do you think is responsible for the activity? 7. Owner/Company Name: 8. Street address: City: 9. Telephone number: (
) -

County:

State:

ZIP code:

10. 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.)

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Indiana Department of Environmental Management Pollution Complaint Clearinghouse State Form 50014 (R3 / 06-05)

Public Pollution Complaint Form

PART C: POLLUTION ACTIVITY DETAILS 11. 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):

12. Please provide the date(s) and duration of the activity. (e.g. 6/12/99-present; 4 hours in the morning):

13. 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):

14. 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):

15. 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:

16. 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):

17. Additional comments:

Thank you for helping to protect our environment! Page 2 of 2