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Illegal Dumping Reporting Form

Please correct the field(s) marked in red below:

1
Please provide as much information as possible. If certain lines won't accommodate your responses, please use the "Additional Comments" section at the bottom of the form.
Date:
2
Your Information
Name:
Address:
Contact Number:
E-mail Address:
3
Do you wish the above contact information remain confidential?
Do you wish the above contact information remain confidential?
4
Dumping Type (select all that apply):
Dumping Type (select all that apply):
Abandoned Vehicle
Tires
Furniture
Yard Waste
Dead Animals
Vehicle Parts (batteries, tires, etc.)
Household Garbage
Appliances
Farm Field Waste
Construction Debris
5
Hazardous Materials (select all that apply):
Hazardous Materials (select all that apply):
Asbestos
Fertilizer
Gasoline
Chemicals
Medical Waste
Oil
Diesel
Poisons
Electronic Devices (TVs, computers, etc.)
Paint Products
6
Other:
7
Select the type of location where dumping occurred:
Select the type of location where dumping occurred:
Roadway (dirt or paved)
Vacant Lot/Land
Canal/River Bank
Waterway (canal/reservoir/river)
Farm Field
8
Address or specific location of dumping:
9

Closest street or landmark:

10
What date did you observe the dumping activity?
11
What time did you observe the dumping activity?
What time did you observe the dumping activity?
12
Did you know the name(s) of the person(s) involved?
Did you know the name(s) of the person(s) involved?
13
Can you describe the person(s) involved?
Can you describe the person(s) involved?
14
Can you describe the vehicle(s) involved?
Can you describe the vehicle(s) involved?
15
If you answered "Yes" to the above question, please provide any or all of the following information:
Vehicle Make
Vehicle Model
Vehicle Year
Vehicle Style (pickup, sedan, SUV, tractor, etc.)
Vehicle Color
License Plate State
License Plate Number
16

Additional Comments:

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