BLUE WATER RESPONSE TEAM INSPECTION SHEET
*REMEMBER…UNBIASED, AS ACCURATE AS POSSIBLE, WITH AS MUCH DETAIL AS YOU CAN.*

Island:       ___ O’ahu    ___ Maui    ___ Hawai’i    ___ Kaua’i    ___ Lana’i    ___ Moloka’i 
 
Contact Person Info: 

Full Name: ____________________________________________________________
 
Date: _______________________ Time:____________________ Location (N, S, E, W): _______
 
Contact Ph #: (___)__________________ Cell #: (___)__________________  Other #: (___)______________

Fax #: (___)_______________ Email:__________________________________________________________ 

Address: ________________________________________________________________________________

Type of Inspection:  ___Complaint Response  ___Routine  ___New Complaint  ___Other________________

Location: _______________________________________________________________________________

Directions to Complaint Site: ______________________________________________________________

________________________________________________________________________________________

Alleged Violator / Site Owner:

Company Name: __________________________________________________________________________

First Name: ____________________ Last Name: _____________________ Title: ______________________

Address: ________________________________________________________________________________

City: ____________________________ State: ___________________ Zip + 4: ________________________

Phone #: (     )__________ Fax: (     )__________ Email: __________________________________________

Permits Obtained: ________________________________________________________________________

Response Team Member Findings / Detailed Description: __________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________

Alleged source of pollution (details): ________________________________________________________

Receiving Waters (waterbody name & type): ___________________________________________________

Example of waterbody type: stream, pond, bay, ocean, etc.

Pictures Taken? (Remember to get these to the Coordinator)

___ Digital	___ Camera (needs developed)       ___ Video	___ Other __________________________

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I, ___________________________________, do declare under penalty of law that the foregoing is true and correct.                
		(full name)
Executed in _______________________________________ on ________________________  ______, 20_____	
		(city, state)                     	     (month)             (day)     (year)

Signature: __________________________________________________

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Coordinator Use ONLY

Action Taken:
____ Verbal Warning: ______________________________________________________________________________
____ Fine Assessed: _______________________________________________________________________________
____ Other: ______________________________________________________________________________________

Follow Up:      Needed (Y/N): ____	Reason: _________________________________________________________
________________________________________________________________________________________________
Referred to (Dept.): ___________________________________ Name: _______________________________________
Ph #: (____)______________  Fax: (____)___________ Email: ____________________________ Date: ____________
 
 
 
 

	        Blue Water Response Team Inspection Sheet
	                * REMEMBER…UNBIASED, AS ACCURATE AS POSSIBLE, WITH AS MUCH DETAIL AS YOU CAN.
Sierra Club Hawai’i Chapter * (808) 537-9019 * P.O. Box 2577, Honolulu, HI 96803 * www.bluewaterhawaii.org