{"status":"success","response":"<div id=\"custom_forms\">\n\n<div class=\"report_row\" id=\"custom_field_row_1\"><h4>Pollution Source<span class='required'> *<\/span> <\/h4><span class=\"custom-field-option\"><label for=\"custom_field[1]\" > Stormwater Outfall <\/label><input type=\"radio\" name=\"custom_field[1]\" value=\"Stormwater Outfall\" id=\"custom_field_1\" \/><\/span><span class=\"custom-field-option\"><label for=\"custom_field[1]\" > Sanitary Sewer Pipe <\/label><input type=\"radio\" name=\"custom_field[1]\" value=\"Sanitary Sewer Pipe\" id=\"custom_field_1\" \/><\/span><span class=\"custom-field-option\"><label for=\"custom_field[1]\" > Sanitary Sewer Manhole <\/label><input type=\"radio\" name=\"custom_field[1]\" value=\"Sanitary Sewer Manhole\" id=\"custom_field_1\" \/><\/span><span class=\"custom-field-option\"><label for=\"custom_field[1]\" > Construction Site <\/label><input type=\"radio\" name=\"custom_field[1]\" value=\"Construction Site\" id=\"custom_field_1\" \/><\/span><span class=\"custom-field-option\"><label for=\"custom_field[1]\" > Industrial Site <\/label><input type=\"radio\" name=\"custom_field[1]\" value=\"Industrial Site\" id=\"custom_field_1\" \/><\/span><span class=\"custom-field-option\"><label for=\"custom_field[1]\" > Other <\/label><input type=\"radio\" name=\"custom_field[1]\" value=\"Other\" id=\"custom_field_1\" \/><\/span><span class=\"custom-field-option\"><label for=\"custom_field[1]\" > Unknown <\/label><input type=\"radio\" name=\"custom_field[1]\" value=\"Unknown\" id=\"custom_field_1\" \/><\/span><\/div><div class=\"report_row\" id=\"custom_field_row_2\"><h4>County Location of Incident<span class='required'> *<\/span> <span class=\"private\">(Private)<\/span><\/h4><span class=\"custom-field-option\"><label for=\"custom_field[2]\" > Baltimore County <\/label><input type=\"radio\" name=\"custom_field[2]\" value=\"Baltimore County\" id=\"custom_field_2\" \/><\/span><span class=\"custom-field-option\"><label for=\"custom_field[2]\" > Baltimore City <\/label><input type=\"radio\" name=\"custom_field[2]\" value=\"Baltimore City\" id=\"custom_field_2\" \/><\/span><span class=\"custom-field-option\"><label for=\"custom_field[2]\" > Anne Arundal County <\/label><input type=\"radio\" name=\"custom_field[2]\" value=\"Anne Arundal County\" id=\"custom_field_2\" \/><\/span><span class=\"custom-field-option\"><label for=\"custom_field[2]\" > Howard County <\/label><input type=\"radio\" name=\"custom_field[2]\" value=\"Howard County\" id=\"custom_field_2\" \/><\/span><span class=\"custom-field-option\"><label for=\"custom_field[2]\" > Other <\/label><input type=\"radio\" name=\"custom_field[2]\" value=\"Other\" id=\"custom_field_2\" \/><\/span><span class=\"custom-field-option\"><label for=\"custom_field[2]\" > Unknown <\/label><input type=\"radio\" name=\"custom_field[2]\" value=\"Unknown\" id=\"custom_field_2\" \/><\/span><\/div><div class=\"report_row\" id=\"custom_field_row_4\"><h4>Date of Initial Pollution Sighting<span class='required'> *<\/span> <\/h4><input type=\"text\" name=\"custom_field[4]\" value=\"\"  id=\"custom_field_4\" class=\"text\" \/><script type=\"text\/javascript\">\n\t\t\t\t$(document).ready(function() {\n\t\t\t\t$(\"#custom_field_4\").datepicker({\n\t\t\t\tshowOn: \"both\",\n\t\t\t\tbuttonImage: \"https:\/\/c683652.ssl.cf2.rackcdn.com\/media\/img\/icon-calendar.gif\",\n\t\t\t\tbuttonImageOnly: true\n\t\t\t\t});\n\t\t\t\t});\n\t\t\t<\/script><\/div><div class=\"report_row\" id=\"custom_field_row_9\"><h4>Date of Follow-Up Pollution Sighting (If Applicable) <\/h4><input type=\"text\" name=\"custom_field[9]\" value=\"\"  id=\"custom_field_9\" class=\"text\" \/><script type=\"text\/javascript\">\n\t\t\t\t$(document).ready(function() {\n\t\t\t\t$(\"#custom_field_9\").datepicker({\n\t\t\t\tshowOn: \"both\",\n\t\t\t\tbuttonImage: \"https:\/\/c683652.ssl.cf2.rackcdn.com\/media\/img\/icon-calendar.gif\",\n\t\t\t\tbuttonImageOnly: true\n\t\t\t\t});\n\t\t\t\t});\n\t\t\t<\/script><\/div><div class=\"report_row\" id=\"custom_field_row_5\"><h4>Date of Pollution Reporting to Agency (If Applicable) <\/h4><input type=\"text\" name=\"custom_field[5]\" value=\"\"  id=\"custom_field_5\" class=\"text\" \/><script type=\"text\/javascript\">\n\t\t\t\t$(document).ready(function() {\n\t\t\t\t$(\"#custom_field_5\").datepicker({\n\t\t\t\tshowOn: \"both\",\n\t\t\t\tbuttonImage: \"https:\/\/c683652.ssl.cf2.rackcdn.com\/media\/img\/icon-calendar.gif\",\n\t\t\t\tbuttonImageOnly: true\n\t\t\t\t});\n\t\t\t\t});\n\t\t\t<\/script><\/div><div class=\"report_row\" id=\"custom_field_row_6\"><h4>Agencies Receiving Pollution Report (Check all that apply) <\/h4><table border=\"0\"><tr><td><span class=\"custom-field-option\"><input type=\"checkbox\" name=\"custom_field[6-0]\" value=\"MDE\" id=\"custom_field_6\" \/><label for=\"custom_field[6]\" > MDE<\/label><\/span><\/td><td><span class=\"custom-field-option\"><input type=\"checkbox\" name=\"custom_field[6-1]\" value=\"MDNR Police\" id=\"custom_field_6\" \/><label for=\"custom_field[6]\" > MDNR Police<\/label><\/span><\/td><\/tr><tr><td><span class=\"custom-field-option\"><input type=\"checkbox\" name=\"custom_field[6-2]\" value=\"Baltimore City DPW\" id=\"custom_field_6\" \/><label for=\"custom_field[6]\" > Baltimore City DPW<\/label><\/span><\/td><td><span class=\"custom-field-option\"><input type=\"checkbox\" name=\"custom_field[6-3]\" value=\"Baltimore City 311\" id=\"custom_field_6\" \/><label for=\"custom_field[6]\" > Baltimore City 311<\/label><\/span><\/td><\/tr><tr><td><span class=\"custom-field-option\"><input type=\"checkbox\" name=\"custom_field[6-4]\" value=\"Baltimore County DEPS\" id=\"custom_field_6\" \/><label for=\"custom_field[6]\" > Baltimore County DEPS<\/label><\/span><\/td><td><span class=\"custom-field-option\"><input type=\"checkbox\" name=\"custom_field[6-5]\" value=\"Baltimore County DPW\" id=\"custom_field_6\" \/><label for=\"custom_field[6]\" > Baltimore County DPW<\/label><\/span><\/td><\/tr><tr><td><span class=\"custom-field-option\"><input type=\"checkbox\" name=\"custom_field[6-6]\" value=\"US Coast Guard\" id=\"custom_field_6\" \/><label for=\"custom_field[6]\" > US Coast Guard<\/label><\/span><\/td><td><span class=\"custom-field-option\"><input type=\"checkbox\" name=\"custom_field[6-7]\" value=\"Other\" id=\"custom_field_6\" \/><label for=\"custom_field[6]\" > Other<\/label><\/span><\/td><\/tr><\/table><input type=\"hidden\" name=\"custom_field[6-BLANKHACK]\" value=\"\"  \/>\n<\/div><div class=\"report_row\" id=\"custom_field_row_7\"><h4>Please Specify Agency Contact(s) and Complaint Tracking Numbers (If Applicable) <\/h4><input type=\"text\" name=\"custom_field[7]\" value=\"\" id=\"custom_field_7\" class=\"text custom_text\" \/><\/div><div class=\"report_row\" id=\"custom_field_row_10\"><h4>Your Phone Number (Optional) <\/h4><input type=\"text\" name=\"custom_field[10]\" value=\"\" id=\"custom_field_10\" class=\"text custom_text\" \/><\/div><\/div>"}