(Sample) Public Works - pothole / street service request
Mar 30, 2017
submission
#1
Submit request
Constituent Information (so that we may respond to your concern)
| Constituent Name | --- |
| Contact email | --- |
| Contact phone | --- |
| Contact preference |
Area of concern / repair request
| Address | 600 Belmont Ave Montebello, CA |
| Type of issue | Lamp / utility box |
| Please describe the problem | There are wires sticking out of the utility box |
| Upload a picture |
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