Report Form for a Natural Resources Environmental Degradation Issue

INSTRUCTIONS: Complete as much of the form as possible. Asterisk (*) denotes a required field. When you are finished, click the 'Submit' button at the end of the Form. Please note that the Division of Environmental Protection may contact you for additional information or clarification if you choose to provide your contact information.

Information About You

Your First Name

Invalid Input

Your Last Name

Invalid Input

Your Preferred Phone Number

Invalid Input

Your Alternate Phone (If you have one)

Invalid Input

Your Email

Invalid Input

Your Street Address

Invalid Input

Your City

Invalid Input

Your State

Invalid Input

Your Zip Code

Invalid Input

Would you like a reply to your complaint submission?

I would like a reply Invalid Input

Would you like to remain anonymous?

I would like to remain anonymous Invalid Input

Description of Pollution - What did you observe?

Date of Observation(*)

Invalid Input

Pollutant / Material(*)

Invalid Input

Other Material

Invalid Input

Pollution Source(*)

Invalid Input

Pollution Cause(*)

Invalid Input

Pollution Destination(*)

Invalid Input

Other Destination

Invalid Input

Date Previously Observed

Invalid Input

Date Previously Reported (If any)

Invalid Input

Please describe your observation of the pollution

Invalid Input

Location of Pollution - Where did you observe this pollution?

Location

Invalid Input

Location Nearest City(*)

Invalid Input

Location Street Address / Intersection(*)

Invalid Input

Location Waterway

Invalid Input

Location Directions

Invalid Input

Alleged Responsible Party - In your opinion, who is responsible?

Responsible Party Individual

Invalid Input

Responsible Party Organization

Invalid Input

Responsible Party Street Address

Invalid Input

Responsible Party City

Invalid Input

Responsible Party State

Invalid Input

Responsible Party Zip Code

Invalid Input

Responsible Party Phone

Invalid Input

Responsible Party Other Information

Invalid Input

Upload any photos you have here

Invalid Input

Either one photo can be uploaded or a ZIP folder with multiple photos.

Please make sure you have filled out as much information as possible before hitting submit!

(*)

Invalid Input