SECTION 1 – Tract Information
Harvest Number:	Inspection Date:	Time:
Incident Number:	County:	Harvest Size To Date:	acres
Location:	Latitude:	Longitude:
Description of Concern:
Describe Corrective Action Needed:
SECTION 2 – Responsible Party Information
Operator	Timber Owner	Landowner
NAID No.:	Name:	Name:
Name:	Address:	Address:
Address:	City/St/Zip:	City/St/Zip:
City/St/Zip:	Phone:	Phone:
Phone:
SECTION 3 – Confirmation
This is an EMERGENCY SPECIAL ORDER. This order is presented under the authority of the Silvicultural Water Quality Law, Article 12, Section 10.1-1181.2(C). The undersigned authorized representative of the State Forester has conducted a field visit and has found that the silvicultural activity that is being conducted at this site is causing or is likely to cause an imminent and substantial danger to (i) the public health, safety or welfare, or the health of animals, fish or aquatic life; (ii) a public water supply; or (iii) recreational, commercial, industrial, agricultural or other reasonable used. Failure to comply may result in the issuance of civil penalties. THIS EMERGENCY SPECIAL ORDER REQUIRES YOU TO STOP WORK IMMEDIATELY EXCEPT FOR CORRECTIVE ACTION. All owners and operators are entitled to a formal hearing or informal conference to affirm, amend, modify or cancel this order. If a hearing or conference is desired, please notify the Virginia Department of Forestry Regional Office within three (3) working days at:
Operator	Timber Owner	Landowner
Name:	Name:	Name:
Signature:	Signature:	Signature:
Date/Time Presented:	Date/Time Presented:	Date/Time Presented:
Copy Delivered:	Copy Delivered:	Copy Delivered:
In Person:	In Person:	In Person:
By Certified Mail No.:	By Certified Mail No.:	By Certified Mail No.:
SECTION 4 – VDOF Inspector Information
Inspector Name (Print)	Inspector Signature	Badge No.	Date
Contact the Virginia Department of Forestry Regional Office Upon Completion of Corrective Action.