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Air Pollution Complaint
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This form has been modified since it was saved. Please review all fields before submitting.
Your Name
*
Your Email Address
Your Phone Number
*
Your Street Address
City
State
Postal/Zip Code
Country
Source of Air Contaminants
Information about the source of air contaminant or location at which the air contaminant was observed (if other than your home).
Do you know the name of the person or the company responsible for the air contaminants?
*
Yes
No
Name (if Known) of Person/Company Discharging the Air Contaminant to the Atmosphere
Company Name (if applicable)
Location Address
City
State
Postal/Zip Code
Country
Phone Number of Responsible Party
Date & Time of Observation
Date/Time
Date/Time
Date/Time
Was the emission of air contaminants continuous or intermittent at that time?
Continuous
Intermittent
Has it occurred before?
Yes
No
Description
Provide more information about the air contaminants or emissions.
Type of Emission
*
Asbestos
Dust
Odor
Paint/Vapors
Smoke/Burning
Other
Wind Conditions
Breezy
Calm
Windy
Direction the Wind Was Blowing from
-- Select One --
From East
From North
From North-East
From North-West
From South
From South-East
From South-West
From West
Complaint or Violation Report
Were you impacted by the air contaminate discharge or are you reporting a potential violation of air pollution regulations?
Complaint or Violation Report
*
Yes, I was impacted by the emissions
No, I am reporting a possible air pollution violation
Describe the air contaminant problem and how you are impacted:
Describe the air contaminant problem that is a potential violation:
Upload & Attach Photos or Documents
Final Requirements
Your completion of the following is required:
Will you testify in court?
*
Yes
No
Certification
*
Notice: The District will not voluntarily disclose the Complainant's (your) identity unless the case goes to court in which case disclosure may be required. However, the District cannot guarantee that the identity of the Complainant will not be deduced due to the circumstances, particularly if the source of air contaminants is nearby and/or the Complainant has had previous interactions with the investigated party. The District may find that some private disputes are not resolvable through District enforcement.
I have read the statement and to my knowledge the entries I have made are truthful and complete.
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