| *Name: |
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| *Phone number: |
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| Email Address: |
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| *Exact or closest address and/or street name: |
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| *Directional location of pole (east, west, north, south side of street): |
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| Select all that apply: |
Damaged pole
Exposed wires
Lights blocked by trees
Light cycling on and off
Light flickering
Light on during daylight hours
Multiple lights out
Open, broken or missing light fixture
Single light out |
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| Any other specific information: |
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