licensed environmental professional state use only complaint no. : d ate received: date referred to the board: complaint


Licensed Environmental Professional
STATE USE ONLY
Complaint No. :
D ate Received:
Date Referred to the Board:
Complaint Form
Please submit a completed Complaint Form regarding a licensed
environmental professional (LEP) to the Board of Examiners of
Environmental Professionals at the address indicated at the end of
this form. Print or type unless otherwise noted.
==================================================================
Part I: General Complaint Information
1. Complaint made by:
Name (Last, First, M.I.):  
Business Name:  
Mailing Address:  
City/Town:   State:   Zip Code:  
Business Phone:   ext.   Fax:  
Contact Person:   Title:  
Email:  
2. LEP who is the subject of the complaint:
Name (Last, First, M.I.):  
Business Name:  
Mailing Address:  
City/Town:   State:   Zip Code:  
Business Phone:   ext.   Fax:  
Email:  
LEP License Number:  
3. Property Location: If the conduct that is the subject of your
Complaint took place at or in connection with a particular property,
please identify that property by either providing its address (street
address and city/town) or by otherwise identifying its location.
Name of facility (if applicable) :  
Street Address or Location Description:  
City/Town:   State:   Zip Code:  
Part II: Allegations
Describe the incident(s) that led to your Complaint and note the times
and dates that events occurred. Please list the names of all
individuals involved.
 
Check here if additional sheets are necessary, and label and attach
them to this sheet.
Attach any additional information or documents needed to explain the
details of your Complaint. Send copies not the originals of any
related documents.
Part III: Authorization for Release of Records and Referral of
Complaint
--------------------------------------------------------------
When you sign this form (or a photocopy thereof), you authorize the
Connecticut State Board of Examiners of Environmental Professionals
to: (1) conduct its own investigation and (2) possibly refer your
Complaint to law enforcement authorities to investigate or prosecute
your Complaint. Please be aware that your Complaint may be shown to
the LEP whose conduct is being investigated.
Please note that all Complaints will be carefully considered; however,
the act of filing a Complaint does not assure or imply that
disciplinary action will necessarily be taken against the licensee.
“I certify that the above information is true, correct and complete to
the best of my knowledge.”
 
Signature
Date
 
 
Name (print or type)
Title (if applicable)
Note: Please submit this completed Complaint Form, and all Supporting
Documents to:
STATE OF CONNECTICUT
BOARD OF EXAMINERS OF ENVIRONMENTAL PROFESSIONALS
REMEDIATION DIVISION, 2nd FLOOR
BUREAU OF WATER PROTECTION AND LAND REUSE
DEPARTMENT OF ENERGY AND ENVIRONMENTAL PROTECTION
79 ELM STREET
HARTFORD, CT 06106-5127
Should you have any questions, please contact Kim Maiorano, Board
Administrator, at [email protected] or 860-424-3788.
DEP- LEPCOMPLAINT-001 Page 2 of 3 Rev. 08/30/18

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