City of Paullina Lead Inventory Survey

Lead Inventory Survey

Please submit a new form for every property.
Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Type of Property:*

Single FamilyMulti-FamilyCommercial
Year Built:*

Before 1988After 1988
1. Water Main

2. Corp Valve

3. Service line (continues into house)

4. Curb Box

5. Curb Stop

6. Shut-off Valve

7. Water Meter

6. Optional secondary shut-off Valve
Use the picture above and pictures at the bottom of survey to help answer questions about your service line and material.
What material is your service line made of? (Check all that apply)*

LeadCopperGalvanized SteelP.E. (polyethylene)Unknown
When was the service line going into your house or business installed?*

Before 1988After 1988Unknown
What material are the pipes in your house or business made of? (Check all that apply)*

LeadCopperGalvanized SteelPVCPEXCPVCUnknownOther
How old are the pipes in your house or business?*

Installed before 1988Installed after 1988Unknown
Do you have a water softener or a whole home water purification system, or any other treatment device installed in your home?*

YesNo
If you answer yes to the question above, do you have an untreated cold-water kitchen or bathroom faucet?*

YesNo
If your home or business meets the criteria for lead and copper sampling would you be willing to participate in this testing? During testing, a Water Supply Employee would bring an empty bottle to your house, provide you with documentation and instructions on collecting the sample, and pick it up the next morning. Sampling frequency is typically every three years.*

YesNo
Please take a picture of your incoming water line and meter, similar to the picture below.
Should be Empty: