Oil and Gas Complaint

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Oil and Gas Related Concern Form

If this is an emergency, please call 911.

Please be patient, you will receive a status update within 5 business days from a city and county representative.
Please note that information submitted via this form is subject to Colorado Open Records Act and may also be included in public reports.

Acknowledge and Continue

Health Symptoms (optional)

Is someone experiencing Health Symptoms that could be related to this complaint

Yes

Who is experiencing these symptoms?

Myself

My Child

Another Family Member

Age

Sex

Male

Female

Please describe the details of the symptoms they are experiencing.

Additional Concerns Information

Description of Concern

What is the issue most noticeable?

Is there visible smoke or emissions?

What is the possible source of the issue?

Text Label

The following "Exposure" questions related to the Concern is being experienced such as your Home or Work - do not select the well pad.

My exposure occurs at

Other

For exposure location, would you like to:

Supply an address

Supply a crossroad

Issue Intersection

Address Line 1

Address Line 2

City:

State:

Zip Code:

Location Description

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Contact Information

Name

Phone

Text Label

Unless a CORA request is made this information is for internal purposes only