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* denotes required field
License Plate
Vehicle Make
Vehicle Model
Color
Date*
Time	12 11 10 9 8 7 6 5 4 3 2 1 00 15 30 45 AM PM
Littered Material Hold CTRL key down and click to select multiple items	Automotive Parts Carpet/Padding Const/Dem Drums Furniture Mattress(es) Oil or other fluids Other Paint Cans Refrigerator/AC/Appliances/TV Tires Trash/Garbage/Litter Yard Waste
Location of Violation*
Nearest Intersection
Description of violator
How did you hear about the program?	< Select Item > Billboard COTA Bus Government Referral Local Event Media Phone Book Police Agency Road Sign Website Other
First Name*
Last Name*
Primary Phone*	- -
Street Address
Apt #/Suite
City
State
Zip
Notes (add other littered materials here)