SECTION 1 – Incident Information
Harvest Number:	Inspection Date:
Tract Number:	Follow-Up Inspection Date:
County:	Latitude:
Acres Cut to Date:	acres	Longitude:
SECTION 2 – Liable Parties
Operator Name:	NAID Number:
Landowner Name(s):	Timber Owner Name(s):
SECTION 3 – Features of Concern
A site visit on this property has identified a situation(s) where water quality degradation may occur. This Water Quality Protection Recommendations form is issued to the Operator(s)/Owner(s) to provide recommended options/suggestions to address these concerns. This is not a notice that you have violated the Virginia Silvicultural Water Quality Law. If the situation is not corrected in a timely manner, a conference may be held to determine if the Silvicultural Water Quality Law has been violated.
Description of Concern(s) Where Pollution is Likely to Occur:
Concern	Corrective Action	Action Type	Deadline
Person On-Site Delivered To:
Sketch of Area(s) of Concern (draw or attach map as needed, include coordinates of concerns):
SECTION 4 – VDOF Inspector Information
Inspector Name (Print)	Inspector Signature	Badge No.	Date