Search this Site                                                    CITIZEN COMPLAINT                                    ILLICIT DISCHARGE REPORTING FORM Name: __________________________________ Contact Phone Number:  _____________________________                                                     Date: ____________                        Time Discharge Discovered: ____________                   Date of Last Rain Event: ______________      Estimated Quantity of Rain: ________ in.                                                                  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 INVESTIGATION:     _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________                                                                                                                                                                                                                                                      Follow 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: