Citizen Complaint Form - Illicit Discharge



CITIZEN COMPLAINT

ILLICIT DISCHARGE REPORTING FORM

 

Name:                                                                 Contact Phone Number:                                 

Date:                                                                  Time Discharge Discovered:                            

 

Date of Last Rain Event:                                                     Estimated Quantity of Rain:        inches

 

LOCATION OF DISCHARGE (indicate nearby street intersections, addresses, and/or landmarks for reference):                                                                                                                                        

                                                                                                                                                         

                                                                                                                                                         

 

 

WHERE WAS DISCHARGE FOUND? OPEN DITCH      STREAM      PIPE OUTFALL    

OTHER:                          

 WAS WATER FLOW OBSERVED?                                NO                   YES                 .

 WAS FLOW SOLID OR PULSING?                               SOLID               PULSING

 WAS A PHOTO TAKEN?           NO                   YES     (Please attach a copy to form)

 ODOR:        NONE         MUSTY       SEWAGE      ROTTEN EGGS       SOUR MILK    

 OTHER:                          

 COLOR:      CLEAR       RED        YELLOW       BROWN         GREEN       GREY    

 OTHER:                             

 CLARITY:      CLEAR       CLOUDY           OPAQUE

 WAS THERE AN:                   OILY SHEEN                                YES                 NO

                                             GARBAGE/SEWAGE                   YES                 NO

                                             OTHER:              

 

ADDITIONAL INFORMATION TO ASSIST IN THE INVESTIGATIONFollow up Investigation (to be completed by CCD staff)

OUTFALL NO:                             INSPECTOR NAME                                                               

PHONE                        

 

FIELD ANALYSIS:

WATER TEMP:                                       °F  /  °C          CHLORINE (Total):                                   mg/l

pH:                                                                               COPPER:                                               mg/l

PHENOL:                                                mg/l                DETERGENTS:                                       mg/l

 

WAS A LABORATORY SAMPLE COLLECTED?             NO                   YES                                       

(if yes attach copy of chain-of-custody record)

COMMENTS:                                                                                                                                                   

                                                                                                                                                                       

                                                                                                                                                                       

 

DATA SHEET FILLED OUT BY:   (signature):                                                                    DATE:                        

 

Additional notes to file:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      

Follow-up with Complainant: