Illegal Discharge Report Form

If you are concerned about potential illegal dumping down a storm drain or illicit discharge into a stream or other body of water, please fill out the form below. Alternatively you can phone the Thomas Jefferson Soil and Water Conservation District at 434-975-0224. Ask for Martin. All personal information will be kept strictly confidential. Any photographs you could provide would also be very helpful. Click on the link at the bottom of this page to send an email and any attachments.

Please provide the following contact information (one or more means of contact as you wish). You are not required to provide any personal information, including your name, but we do need any information you can provide about when, where and what you observed.

First Name:

Last Name:

Home Phone:

Work Phone:

EMAIL:
What type of incident do you wish to report? Check all that apply:
Dumping Down a Storm Drain
Suspicious Discharge from Pipe into a Stream
Water in Stream is an Unusual Color
Water in Stream Smells Strange
Suspicious Suds or other Substance Floating on Water
Fish or other Aquatic Creatures appear to have Died
Where did the incident take place?

Enter the Name of the Street:

Enter the Name of the closest Cross Street:

Enter the Address, if applicable:

Enter the Creek or other body of water Impacted:
Please add any details that might help a responder locate the site and know what to look for to take a sample.

Enter the DATE of the incident:

Enter the TIME of day you made the observation:
You can also send information and photographs by email here.
 
Where did you find out about this web site? Check all that apply:
Daily Newspaper
Weekly Magazine
Radio
Television
Search Engine
Charlottesville Eco-Fair
Other

 

Please specify in more detail how you heard about this web site and this form. This will help us reach the public more effectively.