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2. Name
3. Email Address
5. Address
7. City
8. State
9. Zip Code
11. Phone Number
12. Fax Number
14. Location of Drainage/Flood Issue*

    Detail where the drainage or flooding issue is located.

16. Type of Issue

    1. Clogged Storm Drain
    2. Standing Water
    3. Flooding
    4. Water Pooling
    5. Stagnant Water
    6. Overflow Adjacent Property
18. Additional Comments
20. Upload Photos
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22. 1. Receive an email copy of this form.
23. Email address

    This field is not part of the form submission.

24. Submit

* indicates a required field