(Sample) Public Works - pothole / street service request
Jun 13, 2017
submission
#2
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 | 202 Pico Blvd, Santa Monica CA |
| Type of issue | Street (pothole, etc) |
| Please describe the problem | Pothole in the crosswalk |
| Upload a picture | Sample_Form_citygrows.pdf |
Internal tracking
Resolution
| Picture - before | --- |
| Picture - after | --- |
| Expand on solution | Standard patch |
| List activities | patched pothole |
Constituent feedback
Optional feedback
| How satisfied are you with the level of service you received? | 1 - Very satisfied |
| Please add any additional comments | test |