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Standing Water Report Form

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.

Leave This Blank:


29. 1. Receive an email copy of this form.
30. Email address

    This field is not part of the form submission.

31. Submit

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