4. First Name*
5. Last Name*
7. Address1*
9. Address2
11. City*
12. State*
13. Zip*
15. Email Adress*
16. Mobile Phone Number
18. Select one of the following: Which material is your water service made of?*

    Please be sure to follow the identification instructions carefully. Refer to the Town's website if you are unsure, and make an appointment with a Town representative if you are in need of assistance with the identification of the pipe material.

    1. Copper
    2. Lead
    3. Galvanized Steel
    4. Plastic
    5. Unknown
    6. Other (add to comments below)
19. Is the pipe magnetic?*

    1. Yes
    2. No
21. Upload Image of Pipe (optional)
23. Comments
25. Additional Information

    Please provide any additional information you feel the Town should know regarding your waterline material.

Leave This Blank:


27. 1. Receive an email copy of this form.
28. Email address

    This field is not part of the form submission.

29. Submit

* indicates a required field