Last Updated: December 15, 2017 Please use this form to report any water pollution or issues observed. In cases of large spills or an emergency please do not use this form, but call 9-1-1. *Denotes a required field. Your Contact Information If you wish to remain anonymous, leave all fields blank. If you choose to not provide a means of contact, city staff may be unable to reach you to determine whether or not an investigation is warranted. If you do provide contact information, this information may be used to initiate follow-up communications with you regarding your water pollution observations. Name (First Name, Last Name) Phone Email Location of Event * Include specific driving/walking directions (from nearest intersection, main road, waterway or supply navigational coordinates, if necessary). Description of Incident * If known, please include a description of the type and quantity of material(s) involved. Please indicate if surface waters have been affected. Date of Event * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20222023202420252026 Time of Event * Hour Hour123456789101112 : Minute Minute000102030405060708091011121314151617181920212223242526272829303132333435363738394041424344454647484950515253545556575859 am pm *approximate time is okay Is the incident still occurring? * Yes No Have any other Federal, State, or Local Agencies been notified through additional means (phone call, email, etc.) Please answer either Yes or No. If Yes, please list: * Water level of stream, if in or near stream - None -HighNormalLow If the stream smelled, on a scale of 1 (low) -5 (high), how bad did it smell? 1 2 3 4 5 If the stream smelled, what did it smell like (please describe) Other Conditions & Additional Comments Please describe other conditions, as you are able (Was it windy? Do you remember wind direction? When was the last rain event? Etc.) Information about the person, company or entity responsible for the pollution incident: If you do not know who is responsible for the pollution, please leave the following fields blank. First Name, Last Name Company Name Phone Number Address