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2. Date*
   Date
3. Name*
5. Address*
7. Phone Number*
8. Email*

10. Location of Sidewalk/Curb Ramp:

12. Street Name*
14. Intersecting Street (If Applicable)
16. Other (Address, Landmark, Direction of Travel, Side of Street, etc.)
18. Please Check Applicable ADA Compliance Sidewalk Issues:*

    1. Obstruction
    2. Too Narrow (less than 48 inches wide)
    3. Cross Slope (greater than 2%)
    4. Tripping Hazard
    5. Other
20. Please Explain*
22. Please Check Applicable ADA Compliance Curb Ramp Issues:*

    1. Missing Curb Ramp
    2. Too Steep
    3. Missing or Inadequate Landing Area
    4. Other
24. Please Explain*
Leave This Blank:


26. 1. Receive an email copy of this form.
27. Email address

    This field is not part of the form submission.

28. Submit

* indicates a required field