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2. LOCATION OF PROBLEMATIC STREET LIGHT
4. Brief Description of the Problem*
6. House Number (if known) and Street Name*
8. Nearest Cross Street*
10. City*
11. State
12. Zip Code
14. Pole Number (If Known)
16. Please answer the following three questions about the street lighting issue.
18. Is light blinking on and off?*

    1. Yes
    2. No
19. Does the light stay on all day (24 hours)?*

    1. Yes
    2. No
20. Is the light completely out?*

    1. Yes
    2. No
22. Upload a Photo
26. YOUR INFORMATION
28. First Name*
29. Last Name*
31. House Number and Street Name*
33. City*
34. State
35. Zip Code*
37. Phone Number (Best Daytime Contact)*
39. Email Address
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41. 1. Receive an email copy of this form.
42. Email address

    This field is not part of the form submission.

43. Submit

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