Section 1 of 1 in this document
Storm Drain Cleaning Log
Adopter Information
Individual/Family
Organization/Business
Adopter Name
First Name
*
Last Name
Organization/Business Name
*
Storm Drain Location (nearest address point)
*
Cleaning Date
Month
*
MM
January
February
March
April
May
June
July
August
September
October
November
December
Day
*
DD
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
*
YYYY
2024
2025
2026
2027
2028
2029
2030
Storm drain blockage
Minimal (0-19% covered with litter/debris)
Partial (20-49% covered with litter/debris)
Significant (50-79% covered with litter/debris)
Blocked (80-100% covered with litter/debris)
Amount collected/removed from drain. Please include the units of measure (for example: gallons or pounds)
*
Items collected (check all that apply)
Leaves/twigs/organic litter
Recycling (Plastic bottles, paper, etc)
Cigarette butt(s)
Broken Glass
Straws
Other
Other (please list)
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