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2. Your Name
4. Street Address
6. City/Town
7. Zip
9. Today's Date
   Today's Date
10. Date Water First Noticed
    Date Water First Noticed
12. Daytime Phone
13. Evening Phone
15. Standing Water Information
17. Mosquitoes Present

    1. Yes
    2. No
19. Area of Standing Water

    1. Discarded tires
    2. Pool cover
    3. Unchlorinated pool
    4. Catch basin/sewer
    5. Ditch in ground
    6. Small container
    7. Large container
    8. Pond
    9. Roof gutters
    10. Street depression

    Select all that apply
20. Please Classify the Amount of Standing Water as:

    1. Small (i.e.: bucket, wading pool, etc.)
    2. Medium (i.e.: swimming pool)
    3. Large (i.e.: large flooded outside area)
21. Location of Standing Water

    1. Private house
    2. Apartment building
    3. Business/commercial property
    4. Vacant lot or structure
    5. Public property
23. Other Type of Standing Water
    Please describe
25. Other Location
    Please describe
27. Comments
    Any additional comments.
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29. 1. Receive an email copy of this form.
30. Email address

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31. Submit

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