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2. Village Staff will review all submitted pothole reports and fill potholes as necessary.

4. Address(es) Near Unsafe Pothole(s)

   List out addresses, separated by commas. Please include house numbers and street names.

6. Additional Comments
8. First Name
9. Last Name
11. Phone Number
13. Email Address
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15. 1. Receive an email copy of this form.
16. Email address

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17. Submit

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