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/ISEWAGE YES NO OTHER: ADDITIONAL INFORMATION TO ASSIST IN THE INVESTIGATION: Follow up Investigation (to be completed, by CCD staff) : - OUTFALL NO: INSPECTOR NAME 1 PHONE FIELD ANALYSIS WATER TEMP F/C CHLORINE (Total): mg/l PH: 4 SAAG COPPER: mg/ PHENOL mg/l DETERGENTS mg/l WAS A LABORATORY, SAMPLE COLLECTED? NO YES (if yes attach copy of chain-of-custody, record) COMMENTS 4 a - - AS MAANA DATA: SHEET, FILLED OUT BY: (signature): DATE: A Additional notes to file. MACAS A-XA EXSTPESNAN 4451 A eA 595 A MSEAEA ENEEIESST Follow-up with Complainant - 949457933 ENIACEST AS KXAEA : E 3BSNSRANESS EN NAT A a t pAS E AEN MEA a BP AMA X 4 - A BE Ji