(Sample) Public Works - pothole / street service request
Mar 30, 2017
submission
#9
Submit request
Constituent Information (so that we may respond to your concern)
| Constituent Name | --- |
| Contact preference | Neither / no information |
Area of concern / repair request
| Address | 829 Palm Pl Montebello, CA 90640 |
| Type of issue | Other |
| Please describe the problem | Dead tree |