(Sample) Public Works - pothole / street service request
Mar 30, 2017
submission
#3
Submit request
Constituent Information (so that we may respond to your concern)
| Constituent Name | --- |
| Contact email | --- |
| Contact phone | --- |
| Contact preference | Neither / no information |
Area of concern / repair request
| Address | 137 N Montebello Blvd, Montebello, CA |
| Type of issue | Street (pothole, etc) |
| Please describe the problem | Big pothole! |
| Upload a picture |
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