Standing Water Report Form

Your Name:    
Street Address:
City/Town:     Zip Code:
Daytime Phone:     Evening Phone:
Today's Date:     Date Water First Noticed:

Standing Water Info:
Mosquitoes Present: Yes    No
discarded tires        swimming pool cover        unchlorinated pool
catch-basin/sewer    ditch in ground        small containers (i.e.: bucket, etc.)
large container (i.e.: wading pool, garbage can, refrigerator, etc.)
pond        roof gutters        depression in street (i.e.: pothole, poorly paved street, etc.)
other - Describe:

Please classify the amount of standing water as:
small (i.e.: bucket wading pool, etc.)
medium (i.e.: swimming pool)
large (i.e.: large flooded outside area)

Location of Standing Water:
private house        apartment building        business/commercial property
vacant lot or structure        public property       
other - Describe:

Comments: