Lead & Copper Survey

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What type of plumbing materials are used within the home?

Phone Number *

Fall River Road Utility District 1054 Mattoxtown Rd., Lawrenceburg, TN 38478 Phone: (931) 762-9481

Check all that apply *

Lead (dull, dark gray, (Easily scratched with hard object, shine when scratched)

Copper (copper color, green tarnish)

Known to have lead solder

Galvanized Iron/Steel (Magnetic, black-dark gray, some reddish-brown rust, hard to scratch)

PVC (Plastic Pipe)

Other

Is a water softener installed in your home? *

Yes

Check all that apply: *

Lead (dull, dark gray. Easily scratched with hard object, shiny when scratched)

Copper (copper color, green tarnish)

Know to have lead solder

Galvanized Iron/Steel (Magnetic, black-dark gray, some reddish-brown rust, hard to scratch)

PVC (Plastic Pipe)

Other

Is a permanent water filter installed in your home? *

Yes

Thank you for your interest in protecting your health and the health of your community. To maintain complete records and estimate your home's lead-exposure risk, we ask that you complete this survey.

All required fields are flagged with a red asterisk. Form will not submit without all these fields completed.

What type of service line connects the home to the water meter?

Customer Name: *

Mailing Address: *

Lead and Copper Plumbing Survey

Year of plumbing at main consumption tap: Typically the kitchen sink, if unknown, write UNKNOWN *

Your participation is this program helps protect the health of your community. Please contact us with any questions. Thank you for your assistance, Northeast Utility District

Physical Address: *

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