Residential Lead and Copper Survey 
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Name *
Email *
Address *
Phone number *
Account Number *
Type of Occupancy
 *
Water Service Line Material
(Based on the appearance, testing, or existing records, please select the appropriate material of your water service line.)
 *
Required
Structure – Primary Plumbing Material
(What is the most common plumbing material used in your dwelling?)
 *
Required
Structure – Secondary Plumbing Material
(What is the second most common plumbing material used in your dwelling? Select the same material as above, if only one material is used within the house.)
 *
Required
Source Information
(How did you determine the material of your water service line?)
 *
Required
Line Install Date
(Please provide the install date of your water service line. If you do not know the install date, please provide the year the home was or building was built.)
 *
MM
/
DD
/
YYYY
Plumbing Install Date
(Please select the year (Range) your plumbing was installed, or replaced. If unknown, identify year (Range) structure was built.)
 *
MM
/
DD
/
YYYY
Home Water Filtration System
(Do you have a home water filtration system or softening system, or do you utilize a filtration system connected to a faucet in your dwelling?)
 *
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