(Sample) Public Works - pothole / street service request
Mar 30, 2017
submission
#6
Submit request
Constituent Information (so that we may respond to your concern)
| Constituent Name | --- |
| Contact phone | --- |
| Contact preference | Phone |
Area of concern / repair request
| Address | 310 Whittier Blvd, Montebello, CA 90640 |
| Type of issue | Street (pothole, etc) |
| Please describe the problem | Really big pothole |