Village of Whitehouse Lead Line Customer Survey Question Title * 1. Name Question Title * 2. Street Address Question Title * 3. Do you have a water meter? Yes No Question Title * 4. What is this water meter used for? Drinking Non-Drinking (Irrigation) Combination of Drinking and Non-Drinking Question Title * 5. What material is the utility side made of? Lead Copper Galvanized Plastic Ductile Iron Lined Cast Iron Unlined Cast Iron Unknown Question Title * 6. What material is the house side made of? Lead Copper Galvanized Plastic Ductile Iron Lined Cast Iron Unlined Cast Iron Unknown Question Title * 7. What size pipe is on the utility side of the meter? .75" or 3/4" 1" I don't know Question Title * 8. What size pipe is on the house side of the meter? .75" or 3/4" 1" I don't know Question Title * 9. Have you ever mitigated lead pipes in your home? Yes No Unknown Question Title * 10. What year was your house constructed? If unknown, leave blank. Question Title * 11. Please take a picture of your water meter. Make sure it contains lines on both sides of the meter. PNG, JPG, JPEG file types only. Choose File Choose File No file chosen Remove File Please take a picture of your water meter. Make sure it contains lines on both sides of the meter. Question Title * 12. Acknowledgment: I agree, the information I have provided is accurate and correct to the best of my knowledge. I further agree that the submitted picture of the water meter is at my address listed above. Yes No Done