PA CleanWays Illegal Dumpsite Survey Form

ILLEGAL DUMP SURVEY ASSESSMENT FORM :
(Please fill in all fields. Also do not use the 'Enter' key until you have completed the form.)

GENERAL SITE INFORMATION

Road/Dumpsite Name:

Survey Date (mm/dd/yy)

Primary County

Secondary County

Surveyor Site Number

Primary Municipality

Secondary Municipality

Watershed Name

State or National Forest Name, or State Park Name (if Applicable)

Latitude
(in Decimal Degrees)

Nearest Town

Zip code

Longitude
(in Decimal Degrees)
( Must be a neg.#)

SITE DETAIL

Surveyor (Last, First)

Photos Numbers

Others Attending

DUMP STATUS
Awaiting Cleanup Prior Cleanups Adopted

Area Type

Road Ownership

Traffic Density
Low Moderate High

Type of Area/Road Comments

Directions to Dumpsite (include landmarks, etc.)

Demographics
Rural Suburban Urban

Are 'No Dumping' signs present
Yes No

Dist to nearest Res (in Miles)

Dist to nearest town (in Miles)

Community Cleanup Day
Yes No

Mand. Trash Collection
Yes No

Mandatory Recycling
Curbside Dropoff None

Voluntary Recycling
Curbside Dropoff None

TERRAIN, HISTORY, & SITE USE

Terrain

Terrain Description:

Distance to Water

Name and Description of Waterway/Wetland

Estimated Age of Dumpsite

Dump Character

Site Use
Public Private

History of Dumpsite, including cleanups (if Known)

Distance from Roadway

Visibility from Roadway

SITE CHARACTERISTICS & CONTENTS

Difficulty of Removal/Cleanup

Length of Road
(in miles)

% of Trash
Scattered

Est Truck
Loads

# of Concentrated
Dumps

Suspicious Items
Yes No

Description of Any Suspicious Items

Enter only numbers
Tires
Furniture
Drums
Carcasses
Car Batteries
Mattresses
White Goods
Televisions
Electronics

HHW Yes   No
Clothing Yes   No
C & D Materials Yes   No
Paint Cans Yes   No
Medical Waste Yes   No
Vehicle Parts Yes   No
Recyclables Yes   No
Yard Waste Yes   No
Carpeting Yes   No

Bagged Trash Yes No Clean Fill Yes No Farm Equipment Yes No Household Trash Yes No
Other Contents/Trash (NOT noted above)

Buried or Layered Trash?
Yes No

Isolated Items?
Yes No

Trash Comments

CLEANUP RECOMMENDATIONS

Recommended Deterrents

Narrow Pulloff
Use Rocks
Dirt Mounds

Double Mounding
Guide Rails
Eliminate Pulloff

Close Area
Frequent Patrols
Fencing

SurveillanceCamera
Cleanup
Monitoring

Education
Other (describe below in 'Comments on Deterrents' Field)

Comments on Deterrents

Identified Stakeholders

Hikers
Anglers
Hunters/Sportspersons
Canoers/Boaters

Snowmobilers
Forest Lessees
Campers
Winter Sports

Bikers
Skiers
Birders

Other Stakeholders (Describe Below)

Other Survey Comments (including, but not limited to: other cleanup needs, possible sponsors/donors, safety concerns, and other general site comments)