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First Name* Last Name* Address
Address 2 City
State Zip
Phone Email Address*
- -
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Location of Defect:

Borough:(Choose One)*
Street:*
Side of Street: East West North South
Cross Street #1*
Cross Street #2
Traffic Direction, if known (check one):
Northbound Southbound Eastbound Westbound
Nearest house number, if known:
Description of Landmarks:
What shape is the defect?
Round Square Rectangular Other
If other, please specify:
What are the approximate dimensions?
What is the approximate depth?

Which lane is it in?* Left Right Center Shoulder

Where is it in relation to the street?
Driving Lane Parking Lane Intersection Next to Street Poles


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