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2. Address of Discharge*
4. Email Address*
6. First Name
7. Last Name
9. Discharger Name
11. Discharger Address
13. Your Address
15. Choose from the following:

    1. Item was liquid
    2. Item was clear
    3. Item was gray
    4. Item was green
    5. Item was unknown

    1. Item had a foul odor
    2. Item was solid
    3. Item was brown
    4. Item was yellow
    5. Item was orange
17. Where did the discharge end up? *
    -- Select One --Curb/GutterDitchStormdrainSwale
19. Do you know what was discharged?*
    -- Select One --YesNo
21. If the item emitted odor, was it:
    -- Select One --Rancid/SourSewageSulfidePetroleum/GasOther
23. How much did you see discharged? If known, what was discharged?
25. Did you take photographs of the discharge?*
    -- Select One --YesNo
27. May we contact you for additional information on your observation?*
    -- Select One --YesNo
29. Additional Comments
Leave This Blank:


31. 1. Receive an email copy of this form.
32. Email address

    This field is not part of the form submission.

33. Submit

* indicates a required field