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Illicit Discharge <br /> Incident ID: <br /> Responder Information <br /> Call taken by: T A r Call date: zo Zo <br /> Call time: 0 C( /O Precipitation(inches)in past 24-48 hrs: � <br /> Reporter Information <br /> Incident time: Incident date: b' /'3 Ae 2-,2, <br /> Caller contact information(optional): ct)VI RoNAAG41 4E41-714 b 6'P,—. <br /> Incident Location (complete one or more below) <br /> Latitude and longitude: <br /> Stream address or outfall M <br /> Closest street address: 2- 3 -73 A I p o--� -A <br /> Nearby landmark: I <br /> Primary Location Description Secondary Location Description: <br /> ❑ Stream corridor <br /> In or a.'ace t to stream ❑ �Y Outfall ❑7 In-stream flow ❑Along banks <br /> Upland area Near storm drain Near other water source(storm water pond,wetland,etc.): <br /> ( and not adjacent to stream) <br /> Narrative description of location: <br /> Upland Problem Indicator Description <br /> ❑ Dumping Oil/solvents/chemicals ❑ Sewage <br /> ❑ Wash water,suds,etc. ❑ Other: <br /> Stream Corridor Problem Indicator Description <br /> None ❑ Sewage ❑ Rancid/Sour ❑ Petroleum(gas) <br /> Odor <br /> ❑ Sulfide(rotten eggs); ❑ „Other: Describe in Narrative„section <br /> natural gas <br /> ffq' ❑Oil sheen E]Cloudy ElSuds <br /> Appearance <br /> ❑Other: Describe in"Narrative”section <br /> None: E] Sewage(toilet paper,etc) ❑ Algae E] Dead fish <br /> Floatables <br /> ❑Other: Describe in"Narrative"section <br /> Narrative description of problem indicators: <br /> No1vt IjIFA)es-t� <br /> Suspected Violator(name,personal or vehicle description,license plate#,etc.): <br /> tjS LL)41s-ncS <br /> 37-7 L -Te L'Otj SN c D <br /> o4.1&-re �' S",?- )2— <br /> C-9 <br />