CITIZEN’S COMPLAINT FORM

Please follow up ANY TELEPHONE COMPLAINT with a written complaint.

To: California District Mining Office

Department of Environmental Protection

25 Technology Drive

Coal Center PA 15423

Date: __________

Name: ________________________________________

Address: ________________________________________

________________________________________

Phone: ________________________________________

Mine Operator: ________________________________________

Location of mine: ________________________________________

Name of Mine: ________________________________________

Nature of problem: ________________________________________________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Action requested from the Department of Environmental Protection

____ Cease the violation

____ Request immediate inspection or investigation

____ Request notification of any action

____ Request explanation if no inspection is conducted or enforcement action taken

____ Other(explain) _______________________________________________________

________________________________________________________________________

____ CONFIDENTIALITY IS WAIVED ____ I want to accompany inspector

____ CONFIDENTIALITY IS NOT WAIVED (I understand I will not be able to accompany inspector)