Solid Waste Program Complaint Form

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Anonymous Login Code: Code Entry Page Email
Note: Save this code which is required to update your response at a later time. This code is randomized differently on each page, and despite changing, will still go to the proper response and you only need to save one code.

1.	Date of Incident:*

2.	Complainant remains anonymous?*
	Yes No

3.	Complainant's Name:*

4.	Complainant's Email:

5.	Complainant's Contact Information:*

6.	Complainant from a government agency?
	Yes No

7.	Complainant Agency Name

8.	Location Problem Responsible Party:*

9.	Location Address:*

10.	Location Cross-Road:

11.	Location Problem County:*

12.	Location Problem City:*

13.	Location Problem Zip

Problem Type:

Solid Waste Dumping

Solid Waste Burning

Hazardous Waste

Scrap Tire Dumping

Scrap Tire Unpermitted Facility

Natural Wood Waste

Mass Balloon Release

Sewage Sludge

Composting

PFAS

Coal Combustion

Other

Other, please specify

15.	Problem Description:*