Environmental Resources Management

Environmental Complaint Form

<form name="complaint" onsubmit="return Form_Validate()" action="process_mail.asp" method="post">
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<td valign="top" align="left" width="100%" colspan="2" height="16"><b><font face="Arial" size="2">Please fill out the following information to report an alleged&nbsp;Non-Emergency Environmental C</font></b><font face="Arial" size="2"><b>omplaint, Problem or Violation.</b> <b><br>
</b>(If you wish to remain anonymous, please do not fill out the Complainant Information Section) or you can call the DERM Complaint Desk at: 305-372-6955 (24 hours a day, 7 days a week.)</font> </td>
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<td valign="top" align="left" width="100%" colspan="2" height="16"><font face="Arial" size="2"><b>These fields (<font color="#0000ff">*</font>) require information.</b></font></td>
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<td valign="top" align="left" width="100%" colspan="2"><font face="Arial"><b><font face="Arial" size="2">Environmental Violation/Problem:<br>
</font></b></font></td>
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<td valign="top" align="left" width="123"><b><font face="Arial" size="2"><font color="#0000ff">*</font>Subject of Complaint:</font> <font size="2"><br>
</font></b></td>
<td width="240"><font face="Arial"><input maxlength="256" size="48" name="subject"></font></td>
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<td valign="top" align="left" width="123"><b><font face="Arial, Helvetica, sans-serif" size="2"><font color="#0000ff">*</font> Address:</font></b></td>
<td width="240"><font face="Arial"><input maxlength="256" size="48" name="address_complaint"></font></td>
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<td valign="top" align="left" width="123"><b><font face="Arial, Helvetica, sans-serif" size="2"><font color="#0000ff">*</font>City &amp; Zip:</font></b></td>
<td width="240"><font face="Arial"><input maxlength="256" size="48" name="city_zip_complaint"></font></td>
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<td valign="top" align="left" width="123"><b><font face="Arial, Helvetica, sans-serif" size="2"><font color="#0000ff">*</font>When did this Occur:</font></b></td>
<td width="240"><font face="Arial"><input maxlength="256" size="48" name="when"><br>
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<td valign="top" align="left" width="123"><b><font face="Arial, Helvetica, sans-serif" size="2"><font color="#0000ff">*</font>Description of Violation:</font></b></td>
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<p><font face="Arial"><textarea name="description_of_violation" rows="5" cols="42"></textarea></font></p>
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<td valign="top" align="left" width="163"><b><font face="Arial, Helvetica, sans-serif" size="2">Additional Information:</font></b></td>
<td width="240"><font face="Arial"><textarea name="additional_info" rows="5" cols="42"></textarea></font></td>
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<td valign="top" align="left" width="143" bgcolor="#ffffff" height="23"><b><font face="Arial, Helvetica, sans-serif" size="2"><font color="#0000ff">*</font>E-mail:</font></b></td>
<td valign="top" align="left" width="240" bgcolor="#ffffff" height="23"><font face="Arial" size="2"><input maxlength="256" size="35" name="email"></font></td>
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<td valign="top" align="left" width="100%" bgcolor="#eeeeeb" colspan="2" height="16"><font face="Arial" size="2"><strong>If you wish to remain anonymous, please do not the fill out the contact information below.<br>
</strong></font></td>
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<td valign="top" align="left" width="100%" colspan="2" height="16"><font face="Arial" size="2"><b>Complainant Information:<br>
</b></font></td>
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<td valign="top" align="left" width="143" bgcolor="#ffffff" height="38"><b><font face="Arial, Helvetica, sans-serif" size="2">Name:</font></b></td>
<td valign="top" align="left" width="240" bgcolor="#ffffff" height="38"><font face="Arial" size="2"><input maxlength="256" size="35" name="name"></font> </td>
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<td valign="top" align="left" width="143" bgcolor="#ffffff" height="38"><b><font face="Arial, Helvetica, sans-serif" size="2">Address:</font></b></td>
<td valign="top" align="left" width="240" bgcolor="#ffffff" height="38"><font face="Arial" size="2"><input maxlength="256" size="35" name="Address"></font> </td>
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<td valign="top" align="left" width="143" bgcolor="#ffffff" height="22"><b><font face="Arial, Helvetica, sans-serif" size="2">City &amp; Zip:</font></b></td>
<td valign="top" align="left" width="240" bgcolor="#ffffff" height="22"><font face="Arial" size="2"><input maxlength="256" size="35" name="city_zip"></font></td>
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<td valign="top" align="left" width="143" bgcolor="#ffffff" height="22"><b><font face="Arial, Helvetica, sans-serif" size="2">Day Telephone #:</font></b></td>
<td valign="top" align="left" width="240" bgcolor="#ffffff" height="22"><font face="Arial" size="2"><input maxlength="256" size="35" name="day_phone"></font> </td>
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<td valign="top" align="left" width="143" bgcolor="#ffffff" height="22"><b><font face="Arial, Helvetica, sans-serif" size="2">Night Telephone #:</font></b></td>
<td valign="top" align="left" width="240" bgcolor="#ffffff" height="22"><font face="Arial" size="2"><input maxlength="256" size="35" name="work_num"></font> </td>
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<td valign="top" align="right" width="50%"><input type="button" name="Submit" value="Submit" onClick="validate()">
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<td valign="top" align="left" width="50%"><input type="reset" name="Clear Form" value="Clear Form"></td>
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Back to Top Page Last Edited: Wed Jun 29, 2011 4:30:47 PM