Illicit Discharge

2. 
4. The City of Republic Citizen Request for Service form will help us identify a concern or problem in your area. Should a problem require urgent attention, please call us immediately at 732-3100. For a police or fire emergency, dial 911.

   Thank you for your assistance!

6. First Name*
7. Last Name*
9. Address1*
11. Address2
13. City*
14. State*
15. Zip*
17. Phone Number*
18. Email Address*
20. Please indicate why you're reaching out to us:

    1. Question about City services or government
    2. Comment about City services or government
    3. Concern or complaint about a problem in your neighborhood
22. What is the best way to reach you regarding your question or comment?

    1. Email
    2. Phone (morning)
    3. Phone (afternoon)
    4. I am not requesting a response
24. If you're filing a complaint or concern about an issue in your neghborhood, please tell us more:

    1. Abandoned/Junk Vehicles
    2. Accumulated Junk/ Furniture/Trash
    3. ADA Concern/Request
    4. Animal at Large
    5. Blocked Drainage Channel
    6. Broken/Damaged Sidewalk or Ramp
    7. Blocked Sidewalk or Ramp
    8. Business License Concern
    9. Construction or Zoning Concern
    10. Dogs Barking
    11. Flooding

    1. Graffiti on Public Property
    2. Graffiti on Private Property
    3. Illegal or Hazardous Parking
    4. Litter
    5. Loose/Protruding Manhole Cover
    6. Missing or Obscured Traffic Sign
    7. Mosquitoes
    8. Noise Nuisance
    9. Obstructed Fire Hydrant
    10. Odor Nuisance
    11. Pothole

    1. Report a Blocked Sidewalk
    2. Sewer Backup
    3. Slight Obstruction on Roadway
    4. Speeding
    5. Stormwater Quality (Pollutant Discharge)
    6. Streetlight
    7. Water Leak
    8. Weeds/Tall Grass
    9. Yard Waste Accumulation
    10. Other
26. Brief Description (or other problem not listed)
28. Location of Problem
Leave This Blank:


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

    This field is not part of the form submission.

32. Submit Submit and Print

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