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2. Location of Dumping/Discharge*
3. City
4. Zip
6. Name of Person Reporting Discharge (Optional)
7. Reporting Person's Phone Number
9. Date & Time of Reported Incident*
   Date & Time of Reported Incident

   Date & Time of Reported Incident
11. Discharge Site:*

    1. Residential
    2. Street
    3. Restaurant
    4. Auto-Related

    1. RGO
    2. Industrial Commerical
    3. Auto Dismantling
    4. Other
13. Dumping/Spill (hazardous/toxic materials or sewage) into Storm Drain

    1. Person is dumping material into the Storm Drain
    2. Material is entering Storm Drain as a result of an accidential spill or dumping after-the-fact
15. Non-Stormwater Discharge (Suspected or Actual Illicit Discharge)

    1. Non-storm water is being discharged from site (e.g. residence, commercial or industrial facility) and into storm drain system
    2. Discharge entering catch basin
    3. Discharge entering street, gutter, or alley
    4. Discharge entering channel, river, or ocean
17. Illicit Connection (Actual or Possible)

    1. Curb/Wall Outlet
    2. Pipe or Other Conduit
    3. Other
18. Illicit Discharge Color

    1. Red
    2. Yellow
    3. Green
    4. Black

    1. Brown
    2. Orange
    3. Blue
    4. Cloudy
20. Material(s) that Parially or Wholly Make-up the Discharge

    1. Paper
    2. Plastic
    3. Trash
    4. Vegetation

    1. Oil/Grease
    2. Fecal Matter
    3. Diesel Fuel/Fuel
    4. Soap from Car Wash
21. Discharge Odor - Describe
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23. 1. Receive an email copy of this form.
24. Email address

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25. Submit

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