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2. Date identified*
   Date identified

   Date identified
3. Location*
5. Name*
6. Email Address*
8. Address*
10. City*
11. State*
12. Zip Code*
14. Phone Number*
18. Duration of Problem*
19. Frequency of Problem
23. Description of odor/taste*
    -- Select One --AmmoniaMetalFishyGarlicMedicalRotten EggSkunkChlorine/BeachOther
24. If other, please explain below
26. Color*
    -- Select One --BlueBrownBlackYellowGreenCloudyClearOther
27. If other, please explain below
29. Comments
31. Telephone: 800-826-5721
32. Form 37 – Rev 9/23/19
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34. 1. Receive an email copy of this form.
35. Email address

    This field is not part of the form submission.

36. Submit

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