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2. Name:
3. Contact Number:
5. Incident Date:*
   * Indicates a required field
6. Incident Time:*
   * Indicates a required field
8. Incident Address:
   Or Closest Intersection:*
   * Indicates a required field
10. Description of Location:
12. Type of Problem*

    1. Grass Clippings in Storm Drain
    2. Wash Water or Foaming Visible in Storm Drain
    3. Vehicle Leaks
    4. Sewage Contaminating Storm Drain
    5. Dumping into Storm Drains
    6. Smell in Waterway
    7. Unusual Appearance in Waterway
    8. Debris in Waterway

    * Indicates a required field
14. Description of Problem:
16. Suspected Violator Information:
    (Name, Personal or Vehicle Description,
    License Plate Number, etc.)
18. Upload a Photo
    Optional
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20. 1. Receive an email copy of this form.
21. Email address

    This field is not part of the form submission.

22. Submit

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