First Name

Last Name

Phone

Email

Property Address

Account Number
(Please enter the first six digits of the account number found on your utility bill)

Type of Occupancy Single Family Multi-family Building Other

Water Service Line Material
(Based on the appearance, testing, or existing records, please select the appropriate material of your water service line.)
Lead Copper PVC PEX Galvanized Other Unknown

Source Information
(How did you determine the material of your water service line?)
Visual Inspection Lead Test Kit Plumbing Records Scratch Test Other

Line Install Date
(Please provide the install date of your water service line. If you do not know the install date, please provide the year the home was or building was built.)

Structure – Primary Plumbing Material
(What is the most common plumbing material used in your dwelling?)
Lead Copper PVC PEX Galvanized Other Unknown

Structure – Secondary Plumbing Material
(What is the second most common plumbing material used in your dwelling? Select the same material as above, if only one material is used within the house.)
Lead Copper PVC PEX Galvanized Other Unknown

Plumbing Install Date
(Please select the year (Range) your plumbing was installed, or replaced. If unknown, identify year (Range) structure was built.)

Home Water Filtration System
(Do you have a home water filtration system or softening system, or do you utilize a filtration system connected to a faucet in your dwelling?)
Yes No add/or Softener Unknown