2. Type of Discharge*

   1. Animal Waste
   2. Detergent or Wash Water
   3. Garbage

   1. Industrial Waste
   2. Leaf Litter or Yard Waste
   3. Oil (cooking or petroleum)

   1. Untreated Sewage
   2. Vehicle Fluids
   3. Other Issue
4. Contact Name*
6. Contact Phone Number*
7. Contact Email*
9. Location of Issue Being Reported*
11. Brief Description of Issue and Specifics*
13. Responsible Party*
15. Date of Occurrence*
    Date of Occurrence

    Date of Occurrence
Leave This Blank:


17. 1. Receive an email copy of this form.
18. Email address

    This field is not part of the form submission.

19. Submit

* indicates a required field