Name:____________________________________________ Date: _________________________
Address: ________________________________________________________________________
Telephone: _____________________________
Location of Problem: _______________________________________________________________
Nature of Complaint: _______________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
___________________________________
(Signature)
| Remit form to Contractor: |
Copy Engineer |
| |
Haluch Water Contracting, Inc.
399 Fuller Street, PO Box 510
Ludlow, MA 01056-0510
(413) 583-3196
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|
Underwood Engineers, Inc.
25 Vaughan Mall, Unit 1
Portsmouth, NH 03801
(603) 436-6192 |
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