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?

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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.