Lead & Copper Questionnaire

2. Lead And Copper Participant Survey
4. Thank you for your interest in participating with lead and copper monitoring. To maintain complete records and estimate your home’s risk factor, we ask that you complete this survey.
6. Customer Name*
   First and Last Name
7. Phone Number*
9. Physical Address*
   Street Number and Street Name
11. Mailing Address*
    Street, City, State, Zip
13. Year of Plumbing at Main Consumption Tap:*
    Typically the kitchen sink; if unknown, write "UNKNOWN"
15. Is A Permanent Water Filter Installed In Your Home?*

    Check one box.

    1. Yes
    2. No
16. Is A Water Softener Installed In Your Home?*

    Check one box.

    1. Yes
    2. No
18. What Type of Plumbing Materials Are Used Within The Home?*

    Plumbing Material Can Be Verified By Viewing The Lines Connecting To Your Water Heater And Faucets. Check all that apply.

    1. Lead - (dull, dark grey, similar to pencil lead. easily scratched with hard object, shiny when scratched)
    2. Copper - (copper color, green tarnish)
    3. Galvanized Iron/Steel - (black, some reddish-brown rust, hard to scratch)
    4. Plastic
20. Thank you for your assistance,
    Alan Cranford Plant Manager, Stones River Water Treatment Plant
Leave This Blank:


21. 1. Receive an email copy of this form.
22. Email address

    This field is not part of the form submission.

23. Submit

* indicates a required field