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2. First Name*
3. Last Name*
5. Email Address*
6. Phone Number
7. Business Name
9. Date Discharge Discovered*
10. Time
11. Location of Discharge*
13. Brief Description of Cause
14. Do you have a picture of the incident?*

    1. Yes
    2. No
15. Image Upload

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17. Additional Incident Information*
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19. 1. Receive an email copy of this form.
20. Email address

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21. Submit

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