Complaint Form

Environmental Complaint Form

To better assist DEP in the investigation of your complaint, please provide your name and contact information should further information be necessary. Please note, your information is considered confidential and will not be shared with any party outside DEP Note: Fields marked with an asterisk * are required

Your Information

Name Street Address City Zip

State

Home Telephone Work Telephone Cell phone E-mail Address * Contact me via email * Yes No

Are you or a family member experiencing health symptoms directly related to this concern? *

Yes

No

Complaint Information

* Please use the drop-down menu to select a County from the list *

County of problem *

Location of problem - Township/Borough/City *

Do you know who is responsible? *

Yes No

Responsible Party

Name Address City

Phone State Zip

Problem Description - Please be as specific as possible and include stream names, road names and other information that you think would be helpful

Problem Description

Directions