Lead Service Line Inventory Questionnaire

2. First Name*
3. Last Name
5. Service Address*
7. City
8. State
9. Zip Code
11. Is this address a business or residence?*
    -- Select One --BusinessResidence

    Select one

12. Water lines are made of what type of material?*
    -- Select One --LeadLead-line GalvanizedGalvanizedNon-Lead CopperNon-Lead PlasticNon-Lead OtherUnknown, Likely LeadUnknown, Unlikely Lead
14. Approximately, when were the lines installed?*
15. What size in inches are the lines?*
Leave This Blank:


17. 1. Receive an email copy of this form.
18. Email address

    This field is not part of the form submission.

19. Submit

* indicates a required field