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2. First Name
3. Last Name
5. Address1
7. City
8. State
9. Zip
11. Email
12. Phone Number
14. Service Line Material
    -- Select One --LeadCopperGalvanized SteelUnknownOther

    Please select which type of service line material you have. If your material is not listed below, please select other, and specify in the field below. If you select unknown, please include a picture of the service line in this submittal. 

16. Other

    If you selected other, please specify what type of service line material you have.

18. Picture Upload

    If you selected unknown, please attach a picture of the service line "test area" as shown in the picture below, so our Public Works Department will be able to review and determine what type of service line material you have. 

20. 
Leave This Blank:


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

    This field is not part of the form submission.

24. Submit

* indicates a required field