Pothole Location

Street number and name:*

*

Landmark, intersection, etc:

City:*

State:*

Zip code:

Surface type:*

Asphalt Gravel Other

Location on road surface:*

Travel lane Shoulder Driveway apron Centerline Crosswalk Other

Approximate size:*

Medium Small Large

Noticed date:*

Time:*

Comments:

Photograph:

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Your Information

Name:

Street number and name:

Address line 2:

City:

State:

Zip code:

Phone number:

Email address:

Preferred contact method:*

Do NOT contact me Email