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2. Name
3. Email Address
5. Phone Number
7. Adopting Group/Individual Name
9. Cleanup Date
   Cleanup Date
10. Number of Participants
12. Name of Road Picked Up
14. Number of Bags Collected
16. Already Disposed

    1. Yes
    2. No
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18. 1. Receive an email copy of this form.
19. Email address

    This field is not part of the form submission.

20. Submit

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