Service Line Inventory Form

Please fill in the form below, then add 1-3 photos of the scratched pipe. An example photo is shown below. By submitting a photo, we can verify your pipe material and avoid the need for a future appointment. If you are having difficulty taking or uploading a photo, please contact the Village Clerk.

After filling in the form, click the “SUBMIT” button to send your results to the Village Clerk. Thank you for your help.

Name *

First

Last

Street Address (No P.O. Boxes) *

Address Line 1

City

AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Phone *

Email *

Email

Confirm Email

Are you the owner of the residence? *

• Yes
• No

Owner Name *

First

Last

Owner Address *

Address Line 1

Address Line 2

City

--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Service Line Material? *

• Lead
• Copper
• Galvanized
• PVC (Plastic)

As determined by the scratch test of your service line.

Please attach up to 3 photos of the scratched service line below. A max of 5 MB per photo. The form will accept .png, .gif, and .jpg files *

Click or drag files to this area to upload. You can upload up to 3 files.

files and scratched

Comment or Message

Captcha *

=

Submit