2. Today's Date
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3. First Name*
4. Last Name*
6. May we contact you?*

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7. Telephone Number
9. Please Select Type:*
   -- Select One --PotholeRoad ObstructionSidewalk MaintainenceSign Vandalism or ReplacementDebris in RoadDown Trees
10. Description of issue/problem*
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16. Where is this problem located?
18. Address closest to reported problem:
19. -Or-
20. Nearest intersection:
22. Additional Comments
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