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Complaint Form

Have you detected water contamination, pollution, or other problems in your area?

Cut and paste the following Complaint Form into a Word document, fill in the blanks, and email it to info@ccwi.org. Or, copy and paste it into the comment box when you contact us. We may refer you to the appropriate regulatory agency or your local watershed group, send you factsheets or helpful information, and, when appropriate, assist in arranging testing and monitoring of the affected water source.

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CCWI Complaint Intake Form

Date of Complaint:

Name:

Address:

Phone Number:

Location of Complaint, Including Cross Street:

Name/Address of Property Owner:

Name of Vineyard or Spray Management Company:

Complaint / concerns and activity visibly observed:

Noticeable Effects:
___Dead Vegetation or Wildlife
___Tree Removal
___Stream Degradation
___Erosion
___Grading, Construction

Land Use Nearby:

___Neighborhood
___New Vineyard
___Old Vineyard
___Winery
___Logging
___Agriculture

Well Conditions:
___Cloudy
___Sediment
___Odor, Taste
___Low, Dry
___Pre-Check Document

Comments:

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