St. Clair PSR PA Air Monitoring Project

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Thank you for your interest in participating in our air monitoring project. Please fill this form completely and we will get back to you shortly.

Email *

First Name *

Last Name *

Cell Phone *

Street Address *

City, State *

Zip Code *

Borough or Township
*

County *

Do you live within a 5 mile radius of any of the following types of facilities? *

Landfill

Compressor/Pump Station

Fracking Pad

Orphaned or Abandoned Wells

Gas Powered Energy Generators

Steel Plant

Chemical Plant

Other:

Required

Do you have an outdoor power source near a fence, post or other structure? *

Yes

Is the power source constant?

(For instance, if an inside switch could potentially cut electricity, then your answer would be NO.)

Yes

Do you have wireless internet reception outside the home?
*

Yes

Is your house located...
*

In a valley

On a hill

On a flat expanse of land

Required

Do you believe you're experiencing health impacts because of air quality? If yes, please explain in details, include the length of time you have been exposed to unhealthy air in relation to your health problems. Also if there are other quality of life intrusions such as odor or noise please explain.
*

Do you have any of the following health issues?
*

Asthma

Cardiovascular Disease

Cancer

Autoimmune Disease

Other health Issues

Required

Is there anything else you'd like to share?

Please review the hold harmless agreement. By signing below you agree to all terms.

A copy of your responses will be emailed to the address you provided.

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