Fountain Valley Online Forms

2. Street Light Outage
   Please fill in the information below and provide the location of street light outage.
4. Please provide Requestor Information
   We may need to contact you if we have questions regarding your report.
6. Name*
8. Phone Number*
10. Signal Information
12. Street Number*
13. Street Name*
15. Nearest Cross Street (If applicable)
17. How would you describe the street light outage?*

    1. Light Stays Off
    2. Light Flickering
    3. Light Stays On
19. Do you see any damage to the street light?*

    1. Yes
    2. No
21. Do you see a pole number? (If so, enter here)
23. Please provide any specific or additional information about the outage not covered above:
25. Please attach a photo, if available, of the outage.
27. Thank You.
    Please Allow 2-4 weeks for Street Light Fixtures
Leave This Blank:


29. 1. Receive an email copy of this form.
30. Email address

    This field is not part of the form submission.

31. Submit Submit and Print

* indicates a required field