2. Problem
   Please describe the problem.
4. Location of pothole / problem
   Please provide the physical address of the problem site.
6. Contact Info*

   Please provide an email address or phone number for follow-up information.

8. Picture of problem
   If you'd like to submit a picture of the problem, please upload it here.
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10. 1. Receive an email copy of this form.
11. Email address

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12. Submit Submit and Print

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