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FORM: Citizen-Generated Complaint/Report Form
Instructions: Copy the information below into a word document or an e-mail, or print and mail this modifiable generic form as you wish. Please e-mail suggestions to: projectforsaken@earthlink.net Provide the following information to the best of your knowledge regarding the specific event, its known or suspected source, or its known or suspected effects you are reporting. To make your report easier to classify and locate,
please provide a title and/or file name as follows: For example: Citizen Generated Complaint Report: Barker Floyd Dust 07-11-08
Note to reviewing agency: I would like to make this an official or formal report. If I need to fill out a form specific to your agency or division in order to formalize this reporting action, please advise me of that necessity.
Date of Complaint
Complaint sent to (Please include any agency information or reporting authority who received this report) Agency Date Sumbitted Phone Number Contact Person
Complainant’s Contact Information First and Last Name of Complainant Physical Address Phone Number Cell Phone Number, Work Phone or Other Contact Phone Number E-mail address
Nature of Complaint (Please indicate to the best of your knowledge the following information as it pertains to the event you are reporting. Generally, your complaint may pertain to only one category, but if more than one category applies, please check all that apply immediately below, provide specific information in each category's segment and include all category references in the title/file name) ( ) Odor ( ) Spilled Fluid ( ) Emission ( ) Dust ( ) Other ( ) Health Impacts
Odor 1. When did event occur (please indicate AM or PM / Day / Month /Year) 2. Is it still occurring? 3. Duration of event if it is no longer occurring 4. Event’s proximity to you 5. Description of Odor 6. Intensity of Odor 7. Wind direction 8. Outside Temperature at time of event: 9. Did you observe any unusual circumstances surrounding the event (before, after, during) 10. Who else may have observed this event we can contact for further information: 11. Additional comments and/or pertinent details (observable or potential effects of this event on wildlife, neighbors, etc…)
Spilled Fluid 1. When did event occur (please indicate AM or PM / Day / Month /Year) 2. Is it still occurring? 3. Duration of event if it is no longer occurring 4. Event’s Proximity to you 5. Guesstimated amount of fluid? 6. Is there a water supply nearby (domestic water well, lake, reservoir, stream, river, irrigation ditch, stock pond, etc…? 7. If so, in what proximity is the water supply? 8. Topographical description of area of spilled fluid (hilly, flat, rocky, plowed soil, etc…) 9. Color of fluid: 10. Odor of fluid: 11. Source of fluid spill (tank, truck, etc.): 12. Is the fluid still present? 13. Out side temperature at time of event: 14. Did you observe any unusual circumstances surrounding the event (before, after, during) 15. Who else may have observed this event we can contact for further information 16. Additional comments and pertinent details (observable or potential effects of this event on wildlife, neighbors, etc…)
Emission 1. When did event occur (please indicate AM or PM / Day / Month /Year) 2. Is it still occurring? 3. Duration of event if it is no longer occurring 4. Event’s Proximity to you 5. Color of emission: 6. Is the emission transparent or opaque 7. Source of Event 8. Did you observe any unusual circumstances surrounding the event (before, after, during) 9. Who else may have observed this event we can contact for further information 10. Additional comments and pertinent details (observable or potential effects of this event on wildlife, neighbors, etc…)
Dust 1. When did event occur (please indicate AM or PM / Day / Month /Year) 2. Is it still occurring? 3. Duration of event if it is no longer occurring 4. Event’s proximity to you 5. Source of Event 6. Did you observe any unusual circumstances surrounding the event (before, after, during) 7. Who else may have observed this event we can contact for further information 8. Additional comments and pertinent details (observable or potential effects of this event on neighbors, area wildlife, etc…)
Other Physical Phenomena (impacts to wildlife, domestic animals, vehicle rollovers, etc…) As we cannot anticipate the nature of this category of complaint, please be as descriptive and include as many pertinent details as possible similar to those of above listed events.
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Suspected Health Impacts 1. Description of Impacts you are experiencing: 2. What do you feel is contributing to these impacts? 3. Please tell us why you suspect the health impacts described above are associated with the event(s) you describe herein. 4. Any additional comments and pertinent details:
Photo Attachment(s) if any. If there is more than one photo attached, please duplicate the information below and include it for each photo. If photos are imbedded in the body of this report, please indicate here ( ) and provide the file name below it.
1. Name of photo file: 2. Date of photo: 3. Name of person who took the photo: 4. Description of photo – what are you showing us?
Nearest Drilling Activity: If there is more than one operation occurring in proximity to you, or if you suspect multiple sources, please duplicate the information from this segment below and include it for each potentially relevant operation. If you only know the name of operators working in your vicinity, please include that information below.
1. Proximity to you: 2. Operator: 3. Well Information (name and/or number of well / name of property owner): 4. Operations conducted at time of event (drilling, fracing, transport of fluids, etc.):
Names of operators working in vicinity:
Industry Contact Information 1. Did you notify the operator(s) you suspect may have caused or contributed to this event? 2. Who did you contact? 3. When did you contact them? 4. How did they respond to your concerns? 5. Additional Comments:
END REPORT
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