Citizen Complaint Form
Construction Site Erosion &
Sedimentation
(To be filed with the Township Office)
Date:_______________________
Name of person reporting problem:_______________________________________
Address:____________________________________________________________
Phone number:______________________ Email:__________________________
Location of Problem: (address, subdivision, etc.)_______________________________
_______________________________________________________________________
Description of Problem:___________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Name of person
completing form:__________________________________________
________________________________________________________________________
For Inspector’s Use Only:
Location checked? (yes, no) ___________ Date:_______________ Time:________________
Problem observed? (yes, no) ___________ If yes, what?________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
What corrective actions were
taken, if needed:________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Name of person completing
inspection:_____________________________________________________
Follow-up with Complaintant:______________________________________________________________