Form_4_NCS000250_IDDEP_Report Form_form fill-in 5-13-18

NCDOT NPDES PERMIT HIGHWAY STORMWATER PROGRAM
ILLICIT DISCHARGE DETECTION AND ELIMINATION PROGRAM*
DATE:
FIELD REPORT (FORMALLY ILLICIT CONNECTION Et ILLEGAL DISCHARGE)
Instructions: A DOT supervisory personnel shall investigate, fill in date above, complete information below, and forward
it to Roadside Environmental Unit — Environmental Operations Section. Telephone Number: [phone]; Mailing
Address: NCDOT Roadside Environmental Unit, 1557 Mail Service Center, Raleigh, NC 27699-1557; Fax: [phone]
Pollution Source Observed By: ❑ NCDOT Personnel ❑ NCDOT Contractor ❑ Adopt -A -Highway
Date Identified: ❑ General Public, Name & Phone:
Notes from Reporter:
Investigator Name:
Information: (Last) (First)
Phone: Agency: Position:
Location: NCDOT Division: County: City:
Highway or Site: Nearest Intersection or Mile Post:
Specific Location Info.:
Latitude Longitude (optional)
Type of Stormwater Structure with Illicit Connection or Illegal Dumping (Check One):
❑ Ditch (Size, Type) ❑ Pipe (Size, Type) ❑ Catch Basin
❑ Manhole ❑ Grated Inlet ❑ Other:
Physical Observations: ❑ Dump ❑ Discharge Flow: ❑ Yes ❑ No
Odor:
❑ Sewage ❑ Rotten Eggs ❑ Fishy ❑ Skunk
Vegetation Condition (If applicable):
❑ Petroleum ❑ Other:
❑ None ❑ Normal ❑ Excessive Growth ❑ Inhibited Growth
Color:
❑ Black ❑ Brown ❑ Yellow ❑ Green ❑ Gray
Land Use:
❑ White ❑ Other:
❑ Residential ❑ Commercial ❑ Industrial ❑ Rural
Appearance:
❑ Oily Sheen ❑ Sewage ❑ Chemical
Source: ❑ Residential ❑ Sanitary Sewer ❑ Spill Release
❑ Detergent ❑ Other:
❑ Commercial/Industrial ❑ Other:
I
Comments:
FOR ROADSIDE ENVIRONMENTAL UNIT STAFF USE ONLY
Date Received: Processed By:
(Last) (First)
Forward Report to NCDEQ: ❑ Yes; Date: Whom:
❑ No; Why Not?
Database ID Number: River Basin: Database Entry Date:
(Division) (County) #
Follow Up and Remarks:
Illegal Discharges also include Illegal Dumping as defined as significant materials that are soluble or easily transported by
stormwater runoff, such as used oil, chemical solvents, septic waste. Solid materials not easily transported by stormwater are
addressed through other DOT programs and should not be reported on this form. version 12/4/15