1. Your Name
2. Your Spouse's Name
3. Address
4. City
5. State Select State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
6. Zip Code
7. Phone Number
8. E-mail Address
9. Date

1. Do you own the above home?

1. Yes
2. No

2. If no, are you a tenant?

1. Yes
2. No

3. How long have you resided at the property listed above:

1. Years
2. Months

4. Have you noticed any offensive odors from the Rumpke Landfill at your home?

1. Yes
2. No

5. How long have you experienced the offensive odors at your home?

1. I swear that the above answers are true and accurate to the best of my knowledge.