SAMPLE CITIZEN COMPLAINT FORM

(Your Name)
(Your address)
(Your day-time telephone number)

(Date)

Director, (Name of state regulatory authority)
(State regulatory authority address)

Re: Citizen Complaint of (Your name)

Dear (Name of state regulatory authority director)

In accordance with Sections 517(h) and 521(a) of the Surface
Mining Control and Reclamation Act, I hearby request that you
conduct an inspection without prior notice to the operator of the
(Name of specific mine), (permit number if known), located in
(Name of nearest town).  The mine is operated by the (Name of the
mining company).

I am requesting this inspection because of the conditions or
practices described below which I believe have resulted in
violations of the law.

(Briefly describe the conditions at the mine site which you
believe are resulting in violations of the law. Identify any
condition at the mine site that is causing an imminent danger to
the health and safety of the public, or significant, imminent
harm to the environment.  You may also list actions believed
necessaary to correct the problem)

I hereby waive my right to confidentiality and request the right
to accompany the inspector on the mine site.  You can reach me at
the address and telephone number listed above.  (Alternatively,
you may ask that the state maintain your confidentiality, and not
accompany the inspector on site.)

In accordance with 30 CFR 842.12(d), I request that the (Name of
state regulatory authority) report the results of any inspection
or a detailed explanation in the event that no inspection is
conducted and/or no enforcement action taken.

Very truly yours,

(Sign your name)