Service Line Lead Inventory Survey - Customer

If you have multiple parcels with metered connections to the system, you will need to fill out a separate survey for each

Full Name

First AND last name please

Phone

Service Address

Mailing Address

Water System Name

Year Built

What year was the service line from the meter/shut off to the building inlet installed?

What is the size of the plumbing from the meter/shut off to the building inlet?

Has the service line from the meter/shut off to the building inlet ever been replaced or repaired?

Yes

Unknown

What defines the structure of your home?

Single Family

Multi-Family

Underdeveloped Lot (No Home)

Next you will find descriptions that will help you understand and answer the remaining questions:

The federal Environmental Protection Agency (EPA) defines “lead service line” as a portion of pipe that is made of lead, which connects the water main to the meter and from the meter to the building inlet. A lead service line may be owned by the water system, by the property owner, or both.

The following are considered to be lead service lines (LSL) or "galvanized requiring replacement" (GRR) lines:

-if your service line galvanized iron/steel

AND

- was ever downstream of any lead service line

- a service line made of an unknown material

If the only lead material serving the home is a lead gooseneck, pigtail, or connector, and it is NOT a galvanized service line, then the service line is not a lead service line.

What is the material of the service line, from the water meter to the home inlet?

Please explain (Optional)

Please explain what the material of the service line from the main to the water and water meter to the home inlet?

Was the water line on your lot installed after 1988 or our local lead ban of 1986?

Yes

Unknown

Please explain (Optional)

Please explain was the water line on your lot installed after 1988 or our local lead ban of 1986?

Does the water service line on your property have LEAD SOLDER?

Yes

Unknown

Please explain (Optional)

Please explain does the water service line on your property have LEAD SOLDER?

Were lead pipes used to install the service line on your lot?

Yes

Unknown

Please explain (Optional)

Please explain were lead pipes used to install the service line on your lot?

Are there any interior building plumbing contacts copper pipes with lead solder, installed on or before 1988 or our local lead ban 1986?

Yes

Unknown

Please explain (Optional)

Please explain were there any interior building plumbing contacts copper pipes with lead solder, installed on or before 1988 or our local lead ban 1986?

Describe other fittings and equipment connected to the service line that contain lead (Example: Backflow preventer, meter...)

Is there treatment installed at the point-of-entry or point-of-use?

Yes

Unknown

Please explain (Optional)

Please explain, is there treatment installed at the point-of-entry or point-of-use?

Any pictures of service line plumbing (meter or shut off to home) attach here:

PDF, DOC, DOCX

JPEG, PNG, SVG

Date

Signature

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