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Southern Iowa Rural Water Association
Customer Water Service Line Material Survey
Please complete the survey below. Fields with an asterisk (*) are required.
*
1.
First and Last Name or Business Name on your SIRWA Account *
(Required.)
*
2.
Phone Number
(Required.)
3.
Email (Recommended)
*
4.
Property Address of Water Service
(Required.)
*
5.
Account Number as Shown on Your Invoice
For example: 099-049099-00
(Required.)
*
6.
Type of Water Service
(Required.)
Single Family
Multi-Family
Commercial / Business
Livestock Facility / Confined Livestock
Pasture Meter (grazing livestock)
Other
*
7.
Please visually inspect your water service line after it enters the residence or structure to answer the next question.
Water Service Line Material
(Required.)
Plastic
Copper
Galvanized
Lead
Unknown
Other
*
8.
Year Water Service Line was Installed
Enter the year, for example 1999, or UK for unknown
(Required.)
*
9.
Year Residence or Structure was Constructed *
Enter the year, for example 1999, or UK if unknown
(Required.)
10.
Interior Plumbing Material
Plastic
Copper
Galvanized
Lead
Unknown
Other
*
11.
Year Interior Plumbing was Installed
Enter the year, for example 1999, or UK for unknown
(Required.)
12.
Interior Water Treatment Devices?
Which of these water treatment devices are inside of the residence or structure?
Water Softener
Whole House Filter
Carbon Canister on Faucet
Reverse Osmosis
