2. Section 1 - CUSTOMER INFORMATION
4. First Name
5. Last Name
7. Address1
9. Address2
11. City
12. State
13. Zip
15. Contact Telephone
16. Email Address
20. SECTION 2 - SERVICE LINE IDENTIFICATION
22. Method used to identify the service line entering the residence/building:

    1. Visual inspection
    2. Witnessed installation of the service line
23. Material of the exterior service line:

    1. Lead
    2. Copper
    3. Galvanized Steel

    1. Plastic
    2. Other
25. Material of the interior service line:

    1. Lead
    2. Copper

    1. Galvanized Steel
    2. Plastic

    1. Other
29. SECTION 3 - LOCATION OF SELF-IDENTIFICATION
31. Where was the identification performed?

    1. Foundation
    2. Basement Wall
    3. Floor Slab
    4. Other
35. SECTION 4 - SELF-IDENTIFICATION METHOD
37. Which method was used for identification?

    1. Located a wipe lead joint
    2. Performed a scratch test
    3. Performed a magnet test
41. SECTION 5 - FOLLOW-UP QUESTION FOR GALVANIZED PIPES
43. If galvanized pipe was identified, has lead pipe ever been used ahead of the galvanized pipe?

    1. Yes
    2. No
47. SECTION 6- UPLOAD SUPPORTING PHOTOS
49. Upload a photo showing the self-identification location, labeled with the address:
53. SECTION 7 - CERTIFICATION AND SIGNATURE
55. I certify that all information provided is accurate to the best of my knowledge.

    1. Agree
56. Customer Signature

    Please type your full name. 

58. SECTION 9 - SUBMISSION INSTRUCTIONS

    The form will be submitted automatically upon completion.

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60. 1. Receive an email copy of this form.
61. Email address

    This field is not part of the form submission.

62. Submit

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