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2. If this is an emergency, requiring immediate response, please call 911. If you have information about pollution being dumped or discharged into the storm drainage system, which includes storm drains, creeks, lakes, ponds, streets, or directly into a waterway, please submit this information in this form.
4. Date of Incident
   Date of Incident
5. Incident Time
   Incident Time
7. Incident Location/Address1
8. Incident Location/City
   -- Select One --CampbellLos GatosMonte SerenoSaratogaOther
10. Incident Location is a
    -- Select One --ResidenceBusinessPublic FacilityConstruction SiteRestaurant or Food-RelatedUnknownOther
11. Responsible Party (If Known)
12. Source/Type of Pollution (If Known)
    -- Select One --Antifreeze, oil, paint, or household cleaners dumped or rinsed into the gutterAuto fluids, spilled or dumped on the street or into a storm drainDirt, leaves and lawn clippings that clog storm drainsFoam, bubbles, or a milky appearance in a ditch or waterwayPet waste dumped into storm drainSediment flowing off construction siteSewageSoap and dirt from washing cars in the driveway or streetStrange odor coming from a storm drainWashing equipment outdoors using chemicalsWastewater piped into a creek or ditchOther pollutants
14. Complaint Details
16. It is helpful to have your contact information in case we need to get more information or follow up with you about the report.
18. Name
19. Email
20. Phone
22. How did you learn about us?
    -- Select One --AdvertisingInternetCommunity eventSchoolOther
23. If Other, Please Specify.
25. Upload Photos (If Feasible)
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27. 1. Receive an email copy of this form.
28. Email address

    This field is not part of the form submission.

29. Submit

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