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* 1. Name of person completing this survey: 

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* 2. Phone Number and/or email address 

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* 3. Property Street Address

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* 4. Year Built

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* 5. Structure Type:

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* 6. What pipe material is the service line entering your house, foundation or building made of?

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* 7. What year was your service line installed? (May be year structure built)

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* 8. What size pipe is the service line entering your house or building? (in inches)

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* 9. What material are the plumbing pipes in your house or building mostly made of?

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* 10. What is the second most material the plumbing pipes are made of?

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* 11. How old are the pipes inside your house?

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* 12. Do you have a water softener, a whole home water purification system, reverse osmosis system, faucet filter, or any other treatment device installed in your house or building?

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* 13. If your home or building meets the criteria for lead and copper sampling, would you be willing to participate in testing? This would include RWD10 bringing you an empty bottle and instructions on collecting the sample and picking up the next day. 

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