Lead Copper Survey

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1. Name

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2. Phone Number

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3. Email Address

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4. Account Number

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5. Property Address

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6. Type of Occupancy

Rent

Own

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7. What is your water service line material?

Unknown

Lead (Blue Grey Color)

Copper (Bronze/ Green Color)

Pex (Red or Blue Tubing)

Galvanized (Dull Silver/Grey)

PVC (White Plastic)

HDPE (Black or Blue Plastic)

Other (please specify)

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8. What is the date of your water service line installation: (if unknown, please put the year the home was built)

Date / Time

Date

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9. Source of information

Visual Inspection

Lead Test Kit

Plumbing Records

Scratch Test

Other (please specify)

Lead Copper Survey

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* 1. Name

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* 2. Phone Number

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* 3. Email Address

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* 4. Account Number

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* 5. Property Address

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* 6. Type of Occupancy

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* 7. What is your water service line material?

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* 8. What is the date of your water service line installation: (if unknown, please put the year the home was built)

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* 9. Source of information

1. Name

2. Phone Number

3. Email Address

4. Account Number

5. Property Address

6. Type of Occupancy

7. What is your water service line material?

8. What is the date of your water service line installation: (if unknown, please put the year the home was built)

9. Source of information