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Complaint Information Sheet

2. Date*
   Date

   Please enter today's date.

3. Time*
   Time

   Time

5. General Information

7. Are you an: *

   1. Individual
   2. Public Official
   3. Anonymous

   Please check the appropriate box

8. Do you wish to remain anonymous?*

   1. Yes

   1. No

   (if yes, do not answer the following 3 questions)

10. First Name

11. Last Name

13. Address1

15. Address2

17. City

18. State

19. Zip

21. Phone Number*

23. Complaint Information

25. What is your complaint about:*

27. When did it occur i.e., the date(s) and time(s)*
    When did it occur i.e., the date(s) and time(s)

    When did it occur i.e., the date(s) and time(s)

28. Is it still ongoing?*

    1. Yes

    1. No

30. How are you aware of it e.g., I currently work there, I live nearby?*

32. How are you affected by it?*

34. Can you estimate quantities or size of impacted area?*

36. Can you describe the specific location of the complaint area? e.g., in the back of the green building; on the southwest corner of the property; in the parts washing room?

38. Is the complaint area located in a rural area, residential neighborhood, on an open lot, in a fenced area, is there a stream or water well on the property?*

40. What is the name of the person and/or business you think is responsible (i.e., who is causing the pollution or the reason for your complaint)?*

42. Name the person and/or business. List the address of the complaint.

44. First Name*

45. Last Name*

47. Address1*

49. Address2

51. City*

52. State

53. Zip

55. Phone Number*

57. Please provide driving directions to the location of the complaint, fro example directions from the nearest intersection, main road, legal description. Side of road the complaint is located on, is this visible from the public road?*

59. Have you talked with anybody else about your complaint?

    1. Yes

    1. No

61. If you answered yes, please tell us who you talked to, when you talked to them and what was discussed.

63. This complaint will be sent to the Atchison County Counselor and the Board of County Commissioners for review to see if an investigation may be warranted or if this information should be referred to another agency.

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65. 1. Receive an email copy of this form.
66. Email address

    This field is not part of the form submission.

67. Submit

* indicates a required field