Appendix C-4: Sample Pollution Log

In the sample pollution log below, instructions are in bolded green text to indicate where you need to add information. You can copy and paste the sample log below or download the editable sample log.



Name: [Insert your name]

Date: [Insert the date]

Address: [Insert address where pollution observed]

What did you observe? [Insert brief description of the pollution observed]

Did anyone else observe this? [List any other observers]

For how long did you personally observe this activity? [Insert duration problem was observed]

Did the activity continue after you stopped observing it? For how long? [Insert duration of activity]

Do you think this activity poses a health risk to you or your community?    YES / NO

Why? [Insert brief explanation for why the activity poses a health risk]

Facility Name: [Insert facility information]

Address: [Insert facility address]

Observer Date & Time Location Visible Amount Duration Notes Action Taken