Lead and Copper Survey Form Contact Information Name (required) Address (required) City/Town (required) State/Province (required) Zip/Postal Code (required) Survey Information What year was your house built? (required) What type of construction is your home? (required)Stick Built Manufactured Modular Do you have copper water pipes? (required)Yes No Don't know Do you have any lead water pipes? (required)Yes No Don't know Do you have galvanized water pipes? (required)Yes No Don't know Would you be willing to take water samples for the District?Yes No There was a problem saving your submission. Please try again later. Please wait while your submission is being saved... Submitting...Submit Thank you, your submission has been received.
