VIOLATION COMPLAINT FORM

Please fill out the requested information as completely as possible. This complaint may be mailed, e-mailed, faxed, or delivered in person to the Municipal Building.

Complainant: Phone No.

Date Complaint Filed: Date of Violation:

Can this violation be seen from a public road? Yes No

I give permission for officials to enter my property to investigate this complaint.

Name of property owner where violation occurred:

Exact Location of Violation (Road name, distance and direction from nearest intersection or landmark):

If known, Tax Map Number of Property: 07-0-

Did you speak to the violator about this problem? Yes No Response:

NATURE OF VIOLATION:

Junk Appliances Burning of Materials other than wood or paper Burning Residue

Disturbance of Stream Disturbance of Wetlands Floodway / Waterway Obstruction

Garbage (Food, Household Wastes) Junk / Abandoned Vehicles No Building Permit No Driveway Permit No Sewage Permit No Use Permit Noise Nuisance

Noxious/Toxic Fumes, Runoff Road Encroachment (Road Right of Way)

Safety Hazard Scrap Metal Scrap Wood Junkyard Screening Setback Vio

Sewage on Ground Surface or Sewage Odor Uninhabitable Mobile Home Sign

Old Tires Trash, Rubbish, Worn, or Obsolete Manufactured Goods

Violation of Use Conditions Set By Township Water Pollution Other (Specify)

If known, Ordinance and Section No. Violation:

For Township Use: Date Received: _________________ By: ____________________

Forwarded to: DEP PennDOT Supervisors PSP Conservation District Sewage Enforcement Officer Fish Commission Game commission _____________________________________________________________________