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Water/Sewer Problems Reporting Form

2. Water/Sewer Problems Reporting Form
4. Note:
   Use this form to contact staff between the hours of 7 am and 3 pm, Monday through Friday. After business hours, emergencies can be reported to the Anoka-Champlin Fire Department dispatch at 763-576-2860.
6. Date*
   Date
7. Name*
9. Address*
11. City*
12. State*
13. Zip Code*
15. Email Address
16. Phone Number
18. What the does the problem involve?*

    1. Water
    2. Sewer

    Select all that apply.
19. Is the Water still working?*

    1. Yes, it still works
    2. No, it does not.
20. Is the Sewer still working?*

    1. Yes, it is.
    2. No, it is not.
22. Approximate Time of Water Outage*
23. Approximate Time of Sewer Outage*
25. Comments
Leave This Blank:


27. 1. Receive an email copy of this form.
28. Email address

    This field is not part of the form submission.

29. Submit

* indicates a required field