Citizen Name
Complete this section if you would like to be involved in updates on the issue. This becomes a public record.

City *

Address of the water quality concern.*
Provide nearest address if known

Phone Number
Please complete if you would like follow up contact on the water quality concern.

Please describe the water quality concern. *
If this is an emergency please call the Ohio EPA's Spill Hotline at 1-800-282-9378
Color of the waterSmell of the waterDead fish floatingOther

What other agency have you reported this issue to? *

Date this form was completed. *

*required fields