Form Center

2. Help us Get the Lead Out by self-identifying what type of service line material is coming into your house. See the Lead in Drink Water page for instructions.

   If you have more than three photos to attach, please email the additional photos to Get the Lead Out.

4. Name*
5. Email Address*
7. Address*

   Address is required for mapping purposes.

9. Phone Number*
10. Type of Water Pipe Material*

    1. Lead
    2. Copper
    3. Galvanized
    4. Plastic
12. Attach Photo 1*

    Please use your address as the file name for your photo(s). For example, the file name would look like: 1234 Cleanwater Lane. If you are uploading more than one photo, please add a number at the end. For example: 1234 Cleanwater Lane -1, 1234 Cleanwater Lane -2

13. Attach Photo 2

    Please use your address as the file name for your photo(s). For example, the file name would look like: 1234 Cleanwater Lane. If you are uploading more than one photo, please add a number at the end. For example: 1234 Cleanwater Lane -1, 1234 Cleanwater Lane -2

15. Attach Photo 3

    Please use your address as the file name for your photo(s). For example, the file name would look like: 1234 Cleanwater Lane. If you are uploading more than one photo, please add a number at the end. For example: 1234 Cleanwater Lane -1, 1234 Cleanwater Lane -2

16. Notes
Leave This Blank:


18. 1. Receive an email copy of this form.
19. Email address

    This field is not part of the form submission.

20. Submit

* indicates a required field