Lead and Copper Participant Survey

Download a printable copy of this survey Lead and Copper Participant Survey(PDF, 245KB).

Thank you for your interest in participating with the lead and copper monitoring. To maintain complete records and estimate your home's risk factor, we ask that you complete this survey.

Customer Name * (required)

Phone Number * (required)

Physical Address * (required)

Street, City, State, Zip

Mailing Address * (required)

Street, City, State, Zip

Year of Plumbing at Main Consumption Tap * (required)

Usually the Kitchen sink if unknown type "unknown"

Lead - (dull, dark grey, similar to pencil lead; easily scratched with hard object, shiny when scratch)
Copper - (copper color, green tarnish)
Galvanized Iron/Steel - (black, some reddish-brown rust, hard to scratch)
Plastic