Report Stormwater Pollution Form

Tracking Information
Report Date: 5/16/2012
 
Reporter Information
What time did you discover the pollution?
What day did you discover the pollution?
Select Yes if you would like to be contacted with the result of this investigation.
If Yes is selected, please complete the Contact Information section.

   
First Name: Last Name:
Address:
City:
State: Zip Code:  
       
Phone Number
Email Address  
Incident Location (complete one or more below)
City:
Closest Intersection:

ex: "Blue River at 69 Highway" or "151st and Nall"
Closest Street Address:
Primary Location Description Secondary Location Description
Description of Location:
 
Description of problem in or near a stream
Odor
   
       
Appearance
       
Floatables
 
Description of problem on land away from a stream
 
     
Narrative Description of Pollution Found
Suspected Violator  
     
 

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JOHNSON COUNTY STORMWATER MANAGEMENT PROGRAM
1800 W. 56 Highway
Olathe, KS 66061
Phone: (913) 715-8333
Fax: (913) 715-2453

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