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Clean-up Reporting Form

Please Note:

  • Notify the Volunteer Coordinator with the location of bags from cleanups within two days of each clean-up.
  • Group the trash bags together, and when practical, place them at least 8 feet from the side of the road to make the job of collecting bags easier and safer.
  • Always be aware of your surroundings.
  • Please report any unknown substances or possible hazardous materials by calling 9-1-1. Give a brief description of the problem and the nearest physical address to the problem (street name and block number).
  • DO NOT attempt to clean unknown substances; they can be hazardous to your health
You may also print this form and return by mail or fax (mailing address and fax number located on bottom of printable form).

Anyone who submits a form should be aware that in accordance with the North Carolina Public Records law, found in North Carolina General Statutes Chapter 132, his or her e-mail address is considered public record.

Date of Clean-up:*

Name of Group/Organization:*

E-mail Address:

Name of Clean-up Site:*

Location of Bags/Debris to be picked up:*

Number of Bags Collected:*

Debris Removed (i.e. tires, paper, plastic, etc):*

Actual # of hours spent doing the clean-up:*

Actual # of adult participants:*

Actual # of youth participants (under age 18):*