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2. Date and Time of Illicit Discharge*
   Date and Time of Illicit Discharge

   Date and Time of Illicit Discharge
   Please include estimated date and time illicit discharge was noticed
4. Location of Illicit Discharge
   Please include address, closest intersection, or briefly describe the location of illicit discharge
6. Record any observations about the water (i.e. color, smell, suds):
8. Upload image:
10. Name (optional)
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12. 1. Receive an email copy of this form.
13. Email address

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