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2. Date/Time of Violation*
   Date/Time of Violation

   Date/Time of Violation
4. Street Number*
5. Street Name*
6. Zip*
8. Attach a Picture (Optional)
10. Describe the Violation*
14. Contact Information
    Please fill out the contact information below
16. First Name*
17. Last Name*
19. Phone Number*
20. Email Address*
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22. 1. Receive an email copy of this form.
23. Email address

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24. Submit

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