Citizen Action Form

C_A_R__formCity of Edgewood
2224 104th Avenue East
Edgewood, WA 98372-1513
Phone: 253-952-3299
Fax: 253-952-3537


Date of Complaint:

Would you like a call back on this issue?    Yes      No

I consent to the release of my identifying information with respect to any Public Disclosure of this form.

Pursuant to RCW 42.56.240 (2), I request that my name, phone number, and address be withheld from Public Disclosure to the extent permissible under State Law. However, I acknowledge that disclosure of this information may be requested as part of any ensuing criminal, civil and/or administrative proceedings.

 Your Name*:  
 Your Phone Number*:  
 Your Address:  
 Zip Code:  
Email Address:

Description of the issue: (Please check as many boxes as apply.)

  Nuisance   Storm Water   Vegetation   Building w/o Permits
  Maintenance   Wetlands   Debris   Illegal Structure
  Tree Cutting   Clearing/Grading   Potholes/Streets/Ditches   Septic
    Vehicle Junk/Storage     Other

Please describe if "Other" is selected above:

Site Location:

Parcel Number:


Please describe the problem/hazard in as much detail as possible*:

*Required fields