(Sample) Public Works - pothole / street service request
Mar 30, 2017
submission
#5
Submit request
Constituent Information (so that we may respond to your concern)
| Constituent Name | --- |
| Contact email | --- |
| Contact preference | Neither / no information |
Area of concern / repair request
| Address | 200 W Madison Ave, Montebello, CA 90640 |
| Type of issue | Sidewalk (displacement, crack, etc) |
| Please describe the problem | Big hole in the sidewalk ramp |
Internal tracking
Resolution
| Picture - before | --- |
| Picture - after | --- |
| List activities | n/a no problem observed |
| Notes | Visited site and did not see anything |
Constituent feedback
Optional feedback
| How satisfied are you with the level of service you received? | 1 - Very satisfied |