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2. Date:*
   Date:
4. First Name
5. Last Name
7. Email Address
8. Phone Number
10. Address
12. City
13. State
14. Zip Code
16. Litter Location:*
17. Type of Location:

    1. Paved
    2. Dirt Roadway
    3. Canal
    4. Vacant Lot
    5. Ditch
    6. Riverbank
19. Type of Litter:

    Select all that apply

    1. Tires
    2. Furniture
    3. Yard Waste
    4. Dead Animal
    5. Garbage Bags
    6. Household Garbage
    7. Appliances
    8. Electronics
    9. Construction Debis
    10. Vehicle Parts
20. Hazardous Material:

    Select all that apply

    1. Asbestos
    2. Fertilizer
    3. Gasoline
    4. Chemicals
    5. Medical Waste
    6. Diesel
    7. Paint Products
    8. Poisons
Leave This Blank:


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