Environmental Complaint Form

Environmental Complaint Form

Use this form to submit a complaint or report a possible violation of environmental law or rule.
ADEQ will use the information to follow up on the complaint.

Note: Fields with a * are required. If you choose to submit online, you must complete all the required fields.

Complaint Details

Company/Facility Name:		Company/Facility Address:
Company/Facility Phone #:		Type of Business/Operation:
Major Cross Streets:		*Nearest city:
*County:		If requested, do you have photos/video?
Date of Occurrence: (i.e., 01/01/2013)		Time of Occurrence:
Material Spilled/Dumped:		Estimated Quantity that was spilled/dumped:
Best Time to Witness (if ongoing):		* Type of Pollutant:
*Describe what you saw: Characters Remaining: 2000

Your Information

Note: fields with "*" are required.

*Your name (first, last):		*Address:
*City:		*State:
*Zip:	*	E-mail:
*Phone:
Have you been referred to ADEQ?: Yes No		If yes, by whom:

*Would you like to be contacted about the result of your complaint?: Yes No
Arizona law requires you to provide your name when reporting an alleged violation. Under the law, your name will be placed in the public file unless the release of your name may result in substantial harm to any person, including yourself, or to the public health or safety. See A.R.S. § 41-1010.

*Do you feel that the release of your name may result in substantial harm to any person, including yourself, or to the public health or safety? Yes No If yes, please describe:

Please, only press submit once, otherwise, you will send multiple submittals to us.