NOWWA Compliance Form Compliance Form/Action Request Submitted to NOWWA Date: 11/19/2017 Submitter Name: Not Registered Owner Information Owner Name Property Address: Street or Road City Zip Code 1/4 section of Section Township Range GPS Coordinates Contractor Information Contractor Name Complaint or Problem Not Registered Install/Repair Not in Compliance with Title 124 Regualtions System Registration Number Describe Additional Commnets Keep Confidential? Get a new challenge Write the characters from the image above Note: Electronic submission of any information using this form will identify the provider, or information about the telephone or email address of that person. If you wish to remain anonymous, please indicate that by marking the Keep Confidential box above. The Association will submit the information without disclosing the source thereof. Understand, however, the NDEQ has indicated that the omission of any contact information may limit the ability of the agency to fully investigate the complaint information and could therefore limit the effectiveness of the submission.