Form Center

2. Please use this form to report an issue with the water fill station kiosk.
4. Your Name:*
6. Phone Number:*
8. Email Address:*
10. Date and Time the Issue Occurred:*
    Date and Time the Issue Occurred:

    Date and Time the Issue Occurred:

    An accurate time of the issue is important if you are requesting a refund.

12. If a refund is being requested, please enter the last four digits of the credit used in the transaction(s):
14. Description of Issue:*
16. Each complaint is examined to determine how to best resolve the stated issue. For questions, please contact the Public Works department at 719-581-1046. Thank you.
Leave This Blank:


18. 1. Receive an email copy of this form.
19. Email address

    This field is not part of the form submission.

20. Submit

* indicates a required field