Cal/EPA Environmental Complaint Form

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If you have observed an activity, physical evidence of an activity or have knowledge of what you think may be a possible illegal act or unauthorized release that caused harm or damage to California's public health or environment, the California Environmental Protection Agency (Cal/EPA) would like to know about it. Use this Environmental Complaint Form to file an environmental complaint with 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.

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.)

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:

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.").

Address:

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

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

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

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

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

Air Garbage Pesticides Toxic Substances Water Prop. 65

Date of Occurrence:	Approximate Time:

Ongoing Occurrence? Yes No Unknown

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.):