*
Questionnaire: Please check all that apply:
1. What is your Service Type:
*
Single Family
Multi-Family
Commercial
Industrial
2. What year was the house or business built?:
*
Before 1982
After 1982
Were your internal pipes changed after the original building was built (After 1982), if so what year?
3. What material is your drinking water service line made of prior to entering the home or business? (Check all the apply)
*
Lead
Copper
Galvanized Steel
PVC
Black Plastic
Unknown
4. What material are the drinking water pipes in your house or business made of? (Check all the apply)
*
Lead
Copper
Galvanized Steel
PVC
Black Plastic
Unknown
5. Is your dwelling a Group Home, Child Care Facility, Special Care Facility, Doctor’s Office or Hospital or rental? Please fill out a sheet for each rental property.
Examples of water lines:
Submit
Should be Empty: