Lead Service Line Inventory Questionnaire

Question Title

* 1. Contact Information

Name *

Company (if applicable)

Address *

Address 2

City/Town *

State/Province *

ZIP/Postal Code *

Phone Number *

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* 2. Type of Property

Single Family

Multi-Family (Apartment, Duplex)

Commercial

Industrial

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* 3. Service Line Material

Lead

Copper

Galvanized Steel

Plastic (Polyethylene)

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* 4. Service Line Material Installation Date

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* 5. Is the Point-of-Entry a Water Softener or Whole Home Filtration System?

Yes

No

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* 6. Interior Plumbing Material

Lead

Copper

Galvanized Steel

Plastic (Polyethylene)

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* 7. Interior Plumbing Material Installation Date

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* 8. May the City use this Address for future Lead and Copper Sampling?

Yes

No