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

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:	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.

Your Information


Name:	Your Information
Address:	Your Information
Contact Number:	Your Information
E-mail Address:	Your Information

Do you wish the above contact information remain confidential?

Yes

Dumping Type (select all that apply):


Abandoned Vehicle	Dumping Type (select all that apply):
Tires	Dumping Type (select all that apply):
Furniture	Dumping Type (select all that apply):
Yard Waste	Dumping Type (select all that apply):
Dead Animals	Dumping Type (select all that apply):
Vehicle Parts (batteries, tires, etc.)	Dumping Type (select all that apply):
Household Garbage	Dumping Type (select all that apply):
Appliances	Dumping Type (select all that apply):
Farm Field Waste	Dumping Type (select all that apply):
Construction Debris	Dumping Type (select all that apply):

Hazardous Materials (select all that apply):


Asbestos	Hazardous Materials (select all that apply):
Fertilizer	Hazardous Materials (select all that apply):
Gasoline	Hazardous Materials (select all that apply):
Chemicals	Hazardous Materials (select all that apply):
Medical Waste	Hazardous Materials (select all that apply):
Oil	Hazardous Materials (select all that apply):
Diesel	Hazardous Materials (select all that apply):
Poisons	Hazardous Materials (select all that apply):
Electronic Devices (TVs, computers, etc.)	Hazardous Materials (select all that apply):
Paint Products	Hazardous Materials (select all that apply):

Other:

Select the type of location where dumping occurred:


Roadway (dirt or paved)	Select the type of location where dumping occurred:
Vacant Lot/Land	Select the type of location where dumping occurred:
Canal/River Bank	Select the type of location where dumping occurred:
Waterway (canal/reservoir/river)	Select the type of location where dumping occurred:
Farm Field	Select the type of location where dumping occurred:

Address or specific location of dumping:

Closest street or landmark:

What date did you observe the dumping activity?

What time did you observe the dumping activity?

Did you know the name(s) of the person(s) involved?

Yes

If yes, please provide the description here:

Can you describe the person(s) involved?

Yes

If yes, please provide the description here:

Can you describe the vehicle(s) involved?

Yes

If you answered "Yes" to the above question, please provide any or all of the following information:


Vehicle Make	If you answered "Yes" to the above question, please provide any or all of the following information:
Vehicle Model	If you answered "Yes" to the above question, please provide any or all of the following information:
Vehicle Year	If you answered "Yes" to the above question, please provide any or all of the following information:
Vehicle Style (pickup, sedan, SUV, tractor, etc.)	If you answered "Yes" to the above question, please provide any or all of the following information:
Vehicle Color	If you answered "Yes" to the above question, please provide any or all of the following information:
License Plate State	If you answered "Yes" to the above question, please provide any or all of the following information:
License Plate Number	If you answered "Yes" to the above question, please provide any or all of the following information:

Additional Comments:

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Email Address

Imperial Irrigation District

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