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* 1. Customer Name (First & Last):

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* 2. Account Number:

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* 3. Service Address, City & State receiving ILRW:

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* 4. Service Type:

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* 5. Year the house or business was built (Seeking age of internal pipes):

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* 6. What material is your service line prior to entering the building made of?

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* 7. What material are the pipes in your house or business made of?

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* 8. Do you have a water softener or a whole home water purification system or any other treatment device installed in your house or business once entering the building?

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* 9. If you answered Yes to Question 8, do you have an untreated, cold water kitchen or bathroom faucet not receiving ILRW source water?

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* 10. If your home or business meets the criteria for lead and copper sampling ILRW is required to follow according to EPA, would you be willing to participate in this testing? During testing, an ILRW employee would bring an empty bottle to your house, provide you with documentation and instructions on collecting the sample, and pick it up the next morning. Sampling frequency is typically every 3 years.

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