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2. Contact Information
4. Name of person filling out this questionnaire:
6. Phone number should we have questions:
8. Property Street Address:
10. Structure type:

    1. Single Family Home
    2. Multi-Family (duplex/quadraplex)

    1. Apartment
    2. Commercial Building/Industrial Facility
12. Year Built

14. Materials List (Check all that apply)

16. 1. What pipe material is the service line pipe entering your house, foundation or business made of?

    1. Lead
    2. Copper

    1. Galvanized
    2. PVC

    1. Polyethylene
    2. Unknown
18. 2. What year was your service line installed?

    (This may be the year the structure was built)

20. 3. What size pipe is the service line entering your house or business?

    1. 3/4"

    1. 1"

    1. >1"
22. 4. What material are the plumbing pipes in your house or business mostly made of?

    1. Lead
    2. Copper

    1. Galvanized
    2. PVC

    1. Polyethylene
    2. Unknown
24. 5. What is the second most material the plumbing pipes are made of?

    1. Lead
    2. Copper

    1. Galvanized
    2. PVC

    1. Polyethylene
    2. Unknown
26. 6. How old are the pipes inside your house?

    1. Installed before 1989

    1. Installed after 1989
28. 7. Do you have a water softner, a whole home water purification system, RO-System, faucet filter or any other treatment device installed in your house or business?

    1. Yes
    2. No
30. Please upload a photo of your service line coming into the house.
32. Thank you for your participation!
Leave This Blank:


33. 1. Receive an email copy of this form.
34. Email address

    This field is not part of the form submission.

35. Submit

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