Information Request eForm

INSTRUCTIONS: Use this form to request information from the Minnesota Pollution Control Agency (MPCA) Records Management Unit. If you have any questions, please contact the MPCA Records Management Intake/Triage staff at recordsmanagementintaketriage.pca@state.mn.us or call 651-757-2728 or 1-844-828-0942. All fields marked with an asterisk(*) are REQUIRED to be filled in before the form will submit.

1. Complete the form and click on the “Submit” button at bottom of form to send the form to Records Management staff via OnBase workflow.

2. You will receive an automated email from OnBase once your request is assigned and then again when it is complete.

3. Please fill out one form for each Information Request.

Requester name: (First name Last name)*

Requester email address:*

Date:

Phone number:*

If you enter the Preferred ID and hit the tab key it will autofill facility information.

Preferred ID

Site/Facility Name*

Site address/location:*

County* Press the down arrow key to access the values available for this field or start typing to filter the values

City/Township

Previous site/facility name:

Program(s):

Is this part of another request? Press the down arrow key to access the values available for this field or start typing to filter the values

Describe the information that you need (be as specific as you can):*

file

NOTE: If a requester chooses not to give any identifying information, the MPCA will provide him/her with contact information so that he/she will be able to check on the status of his/her request. However, if the agency file manager handling the request has questions about it but is unable to contact the requester for clarification, this may result in a delay in processing the request.

e-admin11-36 9/1/16

Information Request eForm

Requester Information

Site/Facility Information

Information Requested