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2. This form is to report potholes on Municipal roads only. If the pothole is located on a county road, please 201-646-2808.
4. POTHOLE LOCATION INFORMATION
6. Address, Intersection and/or Notable Landmarks*
8. Photo
9. Date*
   Date
11. YOUR INFORMATION
13. First Name*
14. Last Name*
16. Address*
18. City*
19. State*
20. Zip Code*
22. Phone Number*
24. Email Address*
28. 
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30. 1. Receive an email copy of this form.
31. Email address

    This field is not part of the form submission.

32. Submit

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