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Name:

 

Email Address:

 

Phone Number:

 

Address where Illegal Discharge exists:

 

Street Adress:

 

City:

 

Zip Code:

 

Nearest Cross Street:

 

Type of Violation: Choose Option Illegal Connection Litter,Dump or Stckpile - Trash or Debris - Materials Stored in Water Conveyance Illegal Discharges - Manure - Erosion/Sediment/Aggregate Materials - Soap / Chemicals Other (Please Describe Below)

 

Date and Time:

 

Was a commercial vehicle involved?

Yes
No

 

If so, what was the company name or license plate number on the vehicle?

 

Company Name:

 

License Plate: (State / Number)

 

Please provide a description of your concern below:

 

Please Verify: