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2. Confidentiality Notice: All information reported will remain anonymous and confidential
4. Name
6. Phone Number
8. Email Address
10. Incident Location:
12. Incident Description
14. Source

    1. Commercial
    2. Construction

    1. Industrial
    2. Residential

    1. Unknown
    2. Other
16. Please explain other
18. Type of Material:

    1. Hazardous
    2. Sewage
    3. Wash Water

    1. Building/Construction Materials
    2. Dirt/Sediment
    3. Landscape Debris

    1. Animal Wastes
    2. Litter/Trash

    1. Pool/Spa
    2. Other
20. Please explain other
22. Notes/Probable Cause of Discharge:
Leave This Blank:


26. 1. Receive an email copy of this form.
27. Email address

    This field is not part of the form submission.

28. Submit

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