2. Facility Name
3. Date & Time:
   Date & Time:

   Date & Time:
5. Facility Address
7. Contact Information of the Complaint*
8. Last Name*
10. Address 1*
12. City*
13. State*
14. Zip*
16. Phone Number*
17. Email Address
19. Odor Information:
21. Date Detected:
22. Time Detected:
23. Location Detected:
24. Grid Coordinates:
26. Description of Complaint:
28. Type of Odor:
30. Intensity of Odor:
32. Weather Conditions when odor was detected:
34. Wind Direction and Speed:
35. Rainfall:
36. Temperature:
38. Barometric Pressure:
39. Humidity:
41. Were odors noticed at this location in the past:
43. Remarks (Include information such as special waste being received, wash down of transfer station floor occuring, new gas well installation, location of current working face, etc.)
45. Signature of person making the request*
47. Do you Agree?*

    By clicking "I agree," you agree and acknowledge that 1) your application will not be "Signed" in the sense of a traditional paper document and 2) By signing in this alternate manner, you agree that your "electronic signature" is valid and binding upon you to the same force and effect as a handwritten signature.

    1. I Agree
49. Follow-up Contact with Complaintant
51. Was follow-up contact made with the complaintant?

    1. Yes
    2. No
53. If so, answer the following questions:
55. When was contact made?
    When was contact made?

    When was contact made?
57. By whom and how was contact made?
59. How was the contact made? (Letter, Phone Call, etc.)
61. What issues were discussed with the complaintant?
63. All complaints must include a phone number. The complaint will not be addressed if there is not a valid phone number listed.
65. Complaint #:
Leave This Blank:


67. 1. Receive an email copy of this form.
68. Email address

    This field is not part of the form submission.

69. Submit

* indicates a required field