Water Service Line Inventory Survey

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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:

Single Family

Multi-Family

Commercial

Industrial

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

Before 1982

1982 or After

The internal pipes were changed after the original building was built (After 1982)

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

Lead

Copper

Galvanized Steel

P.E. (polyethylene)

PVC

Unknown

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

Lead

Copper

Galvanized Steel

PVC

PEX

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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?

Yes

No

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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?

Yes

No

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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.

Yes

No