Lead Service Survey

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* 1. Please enter your name

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* 2. Please enter your address

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* 3. Please enter your phone number

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* 5. During which time frame was your house built? Please select one of the following.

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* 6. What is your water service line material?

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* 7. Whole House Filter Present

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* 8. Kindly upload photos of the scratched service line.

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* 9. Kindly upload additional photos of the scratched service line (if needed).

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* 10. Kindly upload additional photos of the scratched service line (if needed).

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* 11. Date Completed

Date

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* 12. If not the homeowner, who performed todays test

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* 13. Additional Comments (Meter Location, Time for Inspection, Final Read, Change Meter)

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* 14. Customer Service Line Material Verification Method

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* 15. Service Line Size

T