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* 1. Street Address (Required)

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* 2. Property Owner Name (Last, First) (Required)

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* 3. Phone (Required)

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* 4. Email Address

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* 5. When was your housebuilt? (Required)

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* 6. Year your water service line was installed? (If unknown, reply UNKNOWN.)

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* 7. To the best of your knowledge, what is your pipe material between the water main and your water meter? (Required)

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* 8. Is a lead connector currently present in the area between the water main and service lines? (e.g. Gooseneck, Pigtail, Other)

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* 9. Was lead ever upstream of this service line? (exclude connector)

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