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


CITIZEN ACTION REQUEST


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.

If the City receives a request for a copy of this form, state law (RCW 42.56.240(2) allows the City to withhold  information revealing the identity of a complainant who believes that disclosure would endanger his/her life, physical safety or property, as long as such request is made at the time of the complaint.  If this applies to you and you would like the City to withhold such information for this reason, check this box.

 



 Your Name*:  
 Your Phone Number*:  
 Your Address:  
 City:  
 State:  
 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:

Landmarks:

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


*Required fields