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1. Name (Required.)

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2. Street Address (Required.)

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3. Do you have a water meter? (Required.)

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4. What is this water meter used for? (Required.)

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5. What material is the utility side made of? (Required.)

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6. What material is the house side made of? (Required.)

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7. What size pipe is on the utility side of the meter? (Required.)

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8. What size pipe is on the house side of the meter? (Required.)

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9. Have you ever mitigated lead pipes in your home? (Required.)

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10. What year was your house constructed? If unknown, leave blank. (Required.)

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11. Please take a picture of your water meter. Make sure it contains lines on both sides of the meter. 

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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. (Required.)

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