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Illicit Discharge Detection Reporting Form
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Please fill out completely and to the best of your ability. Thank you!
Choose from the following:
Checkboxes
Checkbox Description
Checkboxes
Checkbox Description
Item was liquid
Item was solid
The item was clear
The item was brown
The item was gray
The item was yellow
The item was green
The item was orange
The item was unknown
The item had a foul odor
Please provide the following information:
Field Description
Field Data
Required Field
Address of Discharge:
required
Email:
required
Your Name:
Discharger Name:
Discharger Address:
Your Address:
Discharger Phone:
Where did the discharge end up?
Field Data
Swale
Ditch
Stormdrain
Do you know what was discharged?
Field Data
Yes
No
If the item emitted odor, was it:
Field Data
Sewage
Rancid/Sour
Petroleum/Gas
Sulfide
Other
How much did you see discharged? If known, what was discharged?
Did you take photographs of the discharge?
Can we contact you for additional information on your observation?
Additional Comments?
