2. 

3. State and federal governments mandate the City to verify locations with full or partial lead water service lines coming from the water main inside homes.

   We would like to ask your assistance with a lead and copper sampling program. Thank you for taking the time to fill out this form.

5. First Name*
6. Last Name*
8. Address1*
10. Address2
12. Phone Number*
16. Year Home Built*
20. Service Material Coming Into The Residence*

    1. Lead
    2. Copper
    3. Galvanized
    4. Plastic/PVC
21. Inside Plumbing*

    1. Copper
    2. Galvanized
    3. Plastic/PVC
25. Private Water Treatment

    Please check all that apply

    1. Water Softner
    2. Whole House Filter
    3. Under Sink Reverse Osmosis
    4. Other
26. If You Selected Other, Please List Below
Leave This Blank:


28. 1. Receive an email copy of this form.
29. Email address

    This field is not part of the form submission.

30. Submit

* indicates a required field