Cal/EPA Environmental Complaint Form

If you have observed any activity, conduct or physical evidence you suspect to be illegal or unauthorized or have knowledge of suspected illegal or unauthorized conduct impacting, or threatening to impact, Californias environment or the public health, the California Environmental Protection Agency (Cal/EPA) would like to know about it. Please use this Environmental Complaint Form to provide all the details you know and submit the same to Cal/EPA.

If you have a customer service question or would like to provide information to Cal/EPA about your experiences with its Boards, Departments or Office, please complete our Customer Survey Form. We are interested in hearing about your experiences, both positive and negative.

Cal/EPA Complaints Staff Only:

If you are a member of Cal/EPA's Complaints Staff and wish to enter a complaint, please log in first:

Cal/EPA Complaints Staff may access the Cal/EPA Environmental Complaint Form - Tracking and Maintenance pages here:

If this is an emergency, please dial 911 immediately. Is this an emergency? Yes No Is this a spill? Yes No

Your Information:

Do you wish your identity to be kept confidential? Yes No

Check here if you wish to receive information about Cal/EPA's handling of this complaint.
(Be sure to give us a way to contact you.) Yes No

Name:
Address:

City:	State: ZIP Code:

Phone Number: (xxx)xxx-xxxx		E-Mail:

If you work for a governmental entity outside of Ca/EPA and are making a formal agency referral to Cal/EPA, please provide your information below.
Referring External Agency Outside Cal/EPA (If Applicable):
Name of Person from Referring External Agency (If Applicable):

Complaint Information:

Complaint Location

Provide information about the complaint. If you do not know the address, please provide a description of the location (like: "corner of 1st St. and River Blvd."). Note: Please do not include the full text of your complaint here. We will ask you for that in "Complaint Description" below.

Address:

City:	, CA ZIP Code:
County:
Location Description:

Responsible Party

Provide information about the facility, company or person who is allegedly responsible for this problem.

Responsible Person:
Company Name:
Check here if address is the same as above.
Address:

City:	State: ZIP Code:
Phone Number: (xxx)xxx-xxxx

Complaint Type

Complaint Related To: (Click category name for more information.)

Air Solid Waste Pesticides Toxic Substances Water Prop. 65 Other

Complaint Date
Date of Occurrence:	Approximate Time:

Ongoing Occurrence? Yes No Unknown

Complaint Description

Please describe complaint (What happened, what materials or substances were involved, how much is involved, where did the materials or substances go, who else have you reported this to and what was the outcome? Provide any information that will help our inspectors determine the most timely and effective response. Text only.):