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 Address

   Please include the best email address for us to contact you if we need more information on the issue.

9. Specific Location of Illegally Dumped Materials*

   Please provide the address, cross-streets, or other landmark-related information so that the illegally dumped materials can be easily located.

   
   

11. Type(s) of Items Dumped*

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

    Select all that apply. Please add quantity and any item(s) not listed here in the COMMENTS area.

12. Comments

    Number of bags, tires, description of bulky or unusual types of trash, and relevant notes.

14. Does this incident appear to be associated with an unsheltered person?*

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

    If you think the dumping appears to be associated with an unsheltered individual or an encampment, please let us know.

16. Photo of materials dumped

    Please share a photo or a screen cap of a map indicating where the illegal dump is located, or other relevant information.

17. Screen cap of map

    Please share a photo or a screen capture of a map indicating where the illegal dump is located, or other relevant information.

18. More photos, etc.

    Please share a photo or a screen cap of a map indicating where the illegal dump is located, or other relevant information.

20. Thank you for bringing this illegal dumping area to KACCB's attention. We will alert the appropriate ACCGov Department/Division in an effort to get the issue addressed in a timely manner. 

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22. 1. Receive an email copy of this form.
23. Email address

    This field is not part of the form submission.

24. Submit

* indicates a required field