Upstream Oil and Gas Facility Complaint Form

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					                              Upstream Oil and Gas Facility
                                   Complaint Form

Name:                             Signature                               Date

Address:                                                  Phone Number

Are you:    Landowner         Occupant           Other

Land Description        LSD      /Quarter Sec            Twp        Rge           W        M

Lease holder Company Name                                 Facility Type

Is this: Private Land              Public Land

Have you            Inspected the site        Farmed the site      Not been to the site since reclamation.

Do you have photos illustrating your concerns?           Yes       No

Have you informed the company of your concerns?          Yes       No

Please describe your concerns in detail along with the information to support your concerns.
Alberta Environment Regional Offices

Please submit your completed Complaint form to the nearest Alberta Environment

Calgary                                          Lethbridge
Phone: 403/297-8271                              Phone: 403/381-5322
Fax: 403/297-5944                                Fax: 403/382-4428

 2nd Floor, Deerfoot Square                      2nd Floor, Provincial Building
2938 – 11 Street NE                              200 – 5th Avenue South
Calgary, Alberta T2E 7L7                         Lethbridge, Alberta T1J 4C7

Red Deer                                         Edson
Phone: 403/340-7052                              Phone: 780/723-8370
Fax: 403/340-5022                                Fax: 780/723-8386

3rd Floor, Provincial Building                   2nd Floor, Provincial Building
4920 – 51 Street                                 107, 111 – 54 Street
Red Deer, Alberta T4N 6K8                        Edson, Alberta T7E 1T2

Stony Plain
Phone: 780/963-6131
Fax: 780/968-1096

52322 Golf Course Road
Stony Plain, Alberta T7Z 2K9

Edmonton                                         Peace River
Phone: 780/427-7617                              Phone: 780/624-6402
Fax: 780/427-7824                                Fax: 780/624-6542

111, Twin Atria Building                         3rd Floor, Provincial Building
4999 - 98 Avenue                                 9621 – 96 Avenue, Bag 900-31
Edmonton, Alberta T6B 2X3                        Peace River, Alberta T8S 1T4

This form can be forwarded to the local Public Lands or Forest Division office for complaints
dealing with public land.