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2. Your Name*
4. Your Email Address
5. Your Phone Number*
7. Your Street Address
9. City
10. State
12. Postal/Zip Code
13. Country
17. 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).
19. Do you know the name of the person or the company responsible for the air contaminants?*

    1. Yes
    2. No
21. Name (if Known) of Person/Company Discharging the Air Contaminant to the Atmosphere
23. Company Name (if applicable)
25. Location Address
27. City
28. State
30. Postal/Zip Code
31. Country
33. Phone Number of Responsible Party
37. Date & Time of Observation
39. Date/Time
    Date/Time

    Date/Time
41. Was the emission of air contaminants continuous or intermittent at that time?

    1. Continuous
    2. Intermittent
43. Has it occurred before?

    1. Yes
    2. No
47. Description
    Provide more information about the air contaminants or emissions.
49. Type of Emission*

    1. Asbestos
    2. Dust
    3. Odor

    1. Paint/Vapors
    2. Smoke/Burning
    3. Other
51. Wind Conditions

    1. Breezy
    2. Calm
    3. Windy
53. Direction the Wind Was Blowing from
    -- Select One --From EastFrom NorthFrom North-EastFrom North-WestFrom SouthFrom South-EastFrom South-WestFrom West
57. Complaint or Violation Report
    Were you impacted by the air contaminate discharge or are you reporting a potential violation of air pollution regulations?
59. Complaint or Violation Report*

    1. Yes, I was impacted by the emissions
    2. No, I am reporting a possible air pollution violation
61. Describe the air contaminant problem and how you are impacted:
63. Describe the air contaminant problem that is a potential violation:
67. Upload & Attach Photos or Documents
71. Final Requirements
    Your completion of the following is required:
73. Will you testify in court?*

    1. Yes
    2. No
75. 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.

    1. I have read the statement and to my knowledge the entries I have made are truthful and complete.
Leave This Blank:


77. 1. Receive an email copy of this form.
78. Email address

    This field is not part of the form submission.

79. Submit

* indicates a required field