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2. Date/Time
   Date/Time

   Date/Time
3. For After Hours please call (909) 820-3987
5. First Name*
6. Last Name*
8. Address1*
   Customer Address
10. Phone Number*
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11. Email Address
13. Brief Description of Problem*
    Tell us the problem you are having
15. Additional Information
    How long have you been experiencing the problem
17. Have you checked your breakers?*
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    If No, please check before submitting form
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