DEPARTMENT OF ENVIRONMENTAL RESOURCES

 

3800 Cornucopia Way, Suite C   Modesto, CA 95358-9492

Phone: 209.525.6700   Fax: 209.525.6774

 

 

 

FAX COMPLETED FORM TO (209)525-6774

Exact Address of Complaint:>

 

 

 Nearest Cross Street:

 

Site Description: 

                         House                 Apartment         Duplex

                         Empty Lot           Trailer               Mobile Home Park

 

Owners Name, Address and Phone (if known):

 

 

Complaint:

 

 

INFORMATION IN THIS SECTION WILL BE TREATED AS CONFIDENTIAL

 

     Name and Address of person reporting issue: 

      

 

    Daytime Phone Number of person reporting issue: