2. Form Completed By:
4. First Name*
5. Last Name*
7. Address
9. City
10. State
11. Zip Code
13. Phone Number*
14. Email*
16. Incident Discharge & Description Information
18. Date / Time Discharge Discovered*
    Date / Time Discharge Discovered

    Date / Time Discharge Discovered
19. Potential Source of Discharge
21. Street Location*
23. Nearest Water Body (if known)
25. Please check the following boxes, if possible:
27. Nature of Discharge

    1. Continuous
    2. Intermediate
    3. Spill
28. Odor

    1. Gas
    2. Rancid/Sour
    3. Sewage
    4. Sulphur
    5. None
29. Appearance

    1. Clear
    2. Cloudy
    3. Gray
    4. Sheen
    5. Other
30. Solids/Floatables

    1. Fish Kill
    2. Sewage
    3. Tissue
    4. Unknown
    5. None
32. Other Information/Comments
Leave This Blank:


34. 1. Receive an email copy of this form.
35. Email address

    This field is not part of the form submission.

36. Submit

* indicates a required field