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Pollution Report

2. 
4. 1. LOCATION OF INCIDENT:
6. What is the location or address of the incident?
   Include nearby landmarks and identifiers, especially if the address is unknown.
10. 2. COMPLAINT:
12. What did you observe?
    Please be detailed in your response.
14. Type of Runoff or Material

    1. Water
    2. Irrigation Water
    3. Pool or Spa Water
    4. Soapy Water / Graywater
    5. Waste Water / Sewage / Black Water
    6. Dirt / Mud

    1. Litter / Trash / Debris
    2. Household Hazardous Waste (ex. paint, oil, auto fluids)
    3. Construction Materials
    4. Unknown Material
    5. Other
16. Please Explain
    Include details about the material like color and odor.
18. Date and Time of the Observed Incident
    Date and Time of the Observed Incident

    Date and Time of the Observed Incident
    Approximate the time to the best of your ability.
20. What is causing the runoff or pollution threat?
    Include information about nearby activities that may be related to this complaint if cause is unknown.
22. Did the runoff or material reach...

    1. Street / Gutter
    2. Storm Drain
    3. Creek or Stream

    1. Beach
    2. Contained Onsite

    1. Don't Know
    2. Other
24. Please Explain
26. Where is the runoff/material flowing to or where did it stop?
28. How strong is the flow of the runoff?

    1. Trickle or Dripping
    2. Light - Bathroom sink

    1. Medium - Garden Hose
    2. Strong - Fire Hose

    1. Flow is done
    2. Not Applicable
32. 3. YOUR CONTACT INFORMATION:
    This information is kept confidential and will only be used internally. City staff may need to contact you when additional information is needed to understand or resolve the issue.
34. First Name
35. Last Name
37. Phone:
38. Email Address
42. 4. UPLOAD PHOTOS OR VIDEO OF THE INCIDENT
    Please take a photo or video of the incident if possible. You may upload 5 files.
44. Photo or Video Upload
45. Photo or Video Upload
47. Photo or Video Upload
48. Photo or Video Upload
Leave This Blank:


50. 1. Receive an email copy of this form.
51. Email address

    This field is not part of the form submission.

52. Submit Submit and Print

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