EPA VIC Pollution Report Form
Pollution Report
Pollution Type
Please Select
Odour
Noise
Waste
Water
Smoke
Dust
First Name
Last Name
Contact Number
Address
Email
Can you please describe the pollution?
Where are you experiencing this pollution?
How is the pollution impacting you?
Where do you believe the pollution is coming from?
What was the date you experienced this pollution?
What time did you experience this pollution?
Have you experienced this before?
Please Select
Yes
No
When did you first experience this?
Please describe the scale of pollution by stating a number between 1 & 10, with 10 being the worst
Please Select
1
2
3
4
5
6
7
8
9
10
If you can determine the wind direction, please state the direction. If you are unable to, please say unknown.
Is this an ongoing issue?
Please Select
Yes
No
Is this issue still occurring?
Please Select
Yes
No
If our officers need to contact you for further information, are you willing to assist?
Please Select
Yes
No
Would you like to be notified of the outcome of your report?
Please Select
Yes
No
Do you consent for your details to be passed onto other government agencies if required?
Please Select
Yes
No
How is the waste stored?
What is the estimated volume
Are there any indicators that the waste may have been burnt?
Please Select
Yes
No
What are the indicators?
Is the waste suspected to contain asbestos?
Please Select
Yes
No
Is the asbestos fixed or loose?
Please Select
Fixed
Loose
Does the waste contain any soil?
Please Select
Yes
No
Are there any reasons to believe the soil is contaminated?
Please Select
Yes
No
What do you believe the is contaminated with?
What is the nearest street or landmark?
Is the location of the pollution accessible from a public road?
Please Select
Yes
No
Have there been any fish death?
Please Select
Yes
No
Approximately how many fish deaths?
Are the fish dying or decaying
Please Select
Dying
Decaying
Do you have any images or video relating to this report?
You can upload 1 video and up to 3 images
Upload Video
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