2. First Name
3. Last Name
4. Date Reported*
   Date Reported
6. Phone Number
   Best number to reach you at if we have questions.
7. Contact Email
   Please include the best email for us to contact you if we need more information on the issue.
9. Location of Dumping*
   Please include an address, names of the closest cross streets, or other information to help us locate the pile.
11. Dumped Items*

    1. Kitchen or Household Bags
    2. Tires
    3. Furniture
    4. Appliances
    5. Mattress/Box Spring
    6. Construction Debris
    7. Other

    Choose all that apply. Note numbers and items not listed in notes.
12. Comments
    Bag number, tire number, unusual trash types, or other notes.
14. Does this incident appear to be associated with a homeless population?*

    1. Yes
    2. No
    3. Don't Know

    Let us know if this dumping appears to be associated with homeless persons or an encampment.
16. File Upload
    If you have a photo, map, or other information, please share here.
17. File Upload
18. File Upload
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20. 1. Receive an email copy of this form.
21. Email address

    This field is not part of the form submission.

22. Submit

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