Public Works

Illicit Discharge Reporting Form

Public Works

Reporter's Name:
Daytime Phone:	(555-555-5555)
Evening Phone:	(555-555-5555)
E-mail:
Reporter's Observations
Date of discharge sighting:
Time of discharge sighting:
Discharge location:
Type of material being discharged:	Liquid Solid
Enter details here:
Do you wish to be contacted regarding investigation findings?:	Yes No

NOTE: Anonymous reports will be given low priority