City of Belen, The Hub City

Water: Leak, Waste or Stolen Notification Form

Use this form to report a water leak, waste or stolen within the City of Belen. Please complete all information including your name, phone number and e-mail address so that someone from our staff can contact you if necessary. This information will be forwarded to the appropriate department as soon as it is received.
Date:
Name:
Address:
Phone Number:
E-Mail Address:
Would you like to be contacted?: Yes No
Type of Problem: Leak
Waste		 Stolen
Location of Incident:
Describe the Incident: