Water Line Material Self Reporting Form

Phone(Required)

Email

Street Address(Required)

Inlet Pipe Material(Required)

Labeled Inlet Side in picture. Runs from Water Meter to basement floor.

Was street side service line ever previously lead?(Required)

Outlet Pipe Material(Required)

Labeled Outlet Side in picture. Runs from exterior of home up to Water Meter.

Water Meter Body Material(Required)

Date of Original Build

Used to verify installation of water lines in accordance with lead ban.