Gas Well Complaint Form

2. Name

3. Phone Number

4. Email

6. Address*

   Location of the occurence

7. Date/Time *
   Date/Time

   Date/Time

   Date and Time of occurence

8. Level of Alert*
   -- Select One --Low LevelMedium LevelHigh Level

   Please Check One

10. Description of Occurence*

    Please describe your concern in the space provided.

12. Request Action*

    How would you like us to contact you?

    1. Phone
    2. Email
    3. Site visit
    4. Do not contact
13. Contact us
    In case of emergency please call 911. If this is not an emergency but you still wish to alert the City of Cleburne please call 817-556-8883.

    In case of emergency please call 911. If this is not an emergency but you still wish to alert the City of Cleburne please call 817-556-8883.

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14. 1. Receive an email copy of this form.
15. Email address

    This field is not part of the form submission.

16. Submit Submit and Print

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