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* 1. Name

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* 2. Street Address

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* 3. Do you have a water meter?

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* 4. What is this water meter used for?

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* 5. What material is the utility side made of?

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* 6. What material is the house side made of?

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* 7. What size pipe is on the utility side of the meter?

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* 8. What size pipe is on the house side of the meter?

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* 9. Have you ever mitigated lead pipes in your home?

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* 10. What year was your house constructed? If unknown, leave blank.

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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.

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