Form Center

2. Date of Observation
3. Time of Observation
5. Approximate address and/or location of dumping
7. Name and/or description of person discharging (if applicable)
9. Name and Phone Number of person submitting the report
11. Chemical name or identity of any substance involved in the release
13. Is this substance hazardous?

    1. Yes
    2. No
14. Estimate quantity of spill:
15. Did the illicit discharge enter a waterbody? (Lake or Stream)

    1. Yes
    2. No
17. Did the illicit discharge enter the storm drain system? (Manhole, Inlet, or storm drain pipe)

    1. Yes
    2. No
Leave This Blank:


19. 1. Receive an email copy of this form.
20. Email address

    This field is not part of the form submission.

21. Submit

* indicates a required field