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2. Name*
4. Email Address
6. Address*
8. City*
9. State
10. Zip Code
12. Phone Number*
13. Date/Time
    Date/Time

    Date/Time
    Enter a date/time when you discovered the sewer was backed up.
15. Comments on your sewer back up repair request for Anoka Water & Sewer Department?
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17. 1. Receive an email copy of this form.
18. Email address

    This field is not part of the form submission.

19. Submit

* indicates a required field