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2. Please fill out the survey below, attach photo documentation of the pipe that you tested and return the completed survey

4. Property Address*
5. Account Number
7. Name
8. Phone Number
10. Email Address
12. Have you previously had your water service line repaired or replaced?

    1. Yes
    2. No
13. Replace / Repair Documentation
15. If YES -

    Describe what work was done, the year the work was completed and provide us with any supporting documentation your service personnel provided you with (itemized bills, photos, purchase orders, etc.)

17. Water Service Line Identification – Customer Owned

    Please use the service line identification guide to assist with the following questions:

19. Select all materials that apply to your water service line pipe leading up to your home or building.*

    1. Copper
    2. Plastic / Poly

    1. Galvanized Steel or Iron
    2. Lead

    1. Unknown
    2. Can't Locate My Line
21. Select all the different methods you used to determine your service line material

    1. Visual Inspection
    2. Scratch Test

    1. Magnet Test
    2. Lead Swab Test

    1. Plumbing Records
    2. Other
23. Please attach photos of the service line you identified, scratch test or magnet test if applicable.
24. PHOTOS / Attachments*
26. Date Verified*
    Date Verified
27. Person who verified service line*
Leave This Blank:


29. 1. Receive an email copy of this form.
30. Email address

    This field is not part of the form submission.

31. Submit Submit and Print

* indicates a required field