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| Date: | * |
| Name: | * |
| Section #: | |
| Address: | * |
| Phone #: | * |
| Email Address: | * |
| Does the damaged box present a hazardous situation such as broken or sharp metal, tipped or leaning box or wires exposed?: | * |
| What is the address of the box that is damaged?: | * |
| What is the Cross Street where the box is located?: | * |
| What is the box number of the box that is damaged, if one is present?: | |
| What is the location of the box on the property?: | * |
| What is the issue?: | * |
| If other, what is the problem?: | |
* indicates required field
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