Name:
Email:
Phone:

Pollution incident: Please provide as much descriptive information as you can about the location and type of pollution incident, so that we can locate the problem and source. Include the quantity, color, odor and direction of the pollutant. If you do not have a specific address, please indicate a cross street or identifying landmark.

Description of Incident:
Date and Time of Incident:
Location or Address of Incident:
Location Reference: (Distance from landmark or cross streets)
City:
Did the incident happen in the:		Street or alley Catch basin Channel Parking Lot River Lake

Responsible party: If you know or suspect who was responsible for the pollution, dumping or discharge you are reporting, please provide as much information as possible, so that we may contact them. All information remains confidential and is not released.

Company or Individual's Name:
Homeowners's Name:
Contact:
Address:
City:
Phone:
Reference Information: