Road Hazard Report Form

2. The City of Galion Road Hazard Report Form will help us identify problems and get them resolved. Should a problem require urgent attention during business hours, please call 419-468-1857. For a police emergency, dial 911.

4. Contact Information
   Please provide contact information if you would like a response from the City.

   Please provide contact information if you would like a response from the City.

6. First Name*

7. Last Name*

9. Street Address

11. Phone Number*

12. Email Address

14. Please indicate the nature of your problem by checking the appropriate box(es) below:

16. 1. Pothole
    2. Damaged curb
    3. Traffic signals
    4. Weeds
    5. Abandoned vehicles
    6. Chemical discharge
    7. Water leaking

    1. Litter
    2. Road striping
    3. Blocked drainage channel
    4. Street Lights
    5. Damaged sidewalk
    6. Traffic/Road signs

    1. Overhanging trees/shrubs
    2. Hazardous parking
    3. Storm sewer leaking/blockage
    4. Water leaking on roadway
    5. Loose/protruding manhole cover
    6. Fair Housing Complaint
18. Brief Description (or other problem not listed)

20. Location of Problem

    Please provide closest address or nearest cross streets.

22. Photo Upload (optional)

    If you have a picture of the problem, you may upload it here.

Leave This Blank:


24. 1. Receive an email copy of this form.
25. Email address

    This field is not part of the form submission.

26. Submit

* indicates a required field