Lead and Copper Survey

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Questionnaire: Please check all that apply:
1. What is your Service Type:*

Single FamilyMulti-FamilyCommercialIndustrial
2. What year was the house or business built?:*

Before 1982After 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)*

LeadCopperGalvanized SteelPVCBlack PlasticUnknown
4. What material are the drinking water pipes in your house or business made of? (Check all the apply)*

LeadCopperGalvanized SteelPVCBlack PlasticUnknown
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:
Should be Empty:

Questionnaire: Please check all that apply: