Service Line Lead Inventory Survey - System Owner

Full Name

First AND last name please

Phone

Address

Water System Name

What year was the water system built?

What year was the service line from the MAIN to the METER/SHUT OFF installed, at each connection?

Has the service line from the main to the meter/shut off ever been replaced or repaired?

Yes

Unknown

Next you will find descriptions that will help you understand and answer the remaining questions:

The federal Environmental Protection Agency (EPA) defines “lead service line” as a portion of pipe that is made of lead, which connects the water main to the meter and from the meter to the building inlet. A lead service line may be owned by the water system, by the property owner, or both.

The following are considered to be lead service lines (LSL) or "galvanized requiring replacement" (GRR) lines:

- if your service line galvanized iron/steel

AND

- was ever downstream of any lead service line

- a service line made of an unknown material

If the only lead material serving the home is a lead gooseneck, pigtail, or connector, and it is NOT a galvanized service line, then the service line is not a lead service line.

What is the material of the service line, from the water meter to the home inlet?

Please explain (Optional)

Please explain what the material of the service line, from the main to the water meter and water meter to the home inlet?

Does the water service line from the main to the water meter have LEAD SOLDER on any of the service connections?

Yes

Unknown

Please explain (Optional)

Please explain, does the water service line from the main to the water meter have LEAD SOLDER on any of the service connections?

Were lead pipes used to install the service line from the water main to the water meter at any of the service lines?

Yes

Unknown

Please explain (Optional)

Please explain, were lead pipes used to install the service line from the water main to the water meter at any of the service lines?

Do you have a list of service lines on the water system? If yes, is this list in paper/electronic format?

Yes

Unknown

Please explain (Optional)

Please explain, if you have a list of service lines on the water system? If yes, is this list in paper/electronic format?

Do you have as-built records indicating the service line material for each service line on the water system? If yes, are these records in paper/electronic format?

Yes

Unknown

Please explain (Optional)

Please explain if you have as-built records indicating the service line material for each service line on the water system? If yes, are these records in paper/electronic format?

What is the size of the plumbing from the water main to the water meter/shut off?

Describe other fittings and equipment connected to the service line that contain lead. (Example: backflow preventer, water meter.)

Is there treatment installed at the point-of-entry or point-of-use?

Yes

Unknown

Please explain (Optional)

Please explain if the treatment installed is at the point-of-entry or point-of-use?

Any pictures of service line plumbing (meter or shut off to home) attach here:

PDF, DOC, DOCX

JPEG, PNG, SVG

Date

Signature

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