2. Residential Cross-Connection and LEAD Line Questionnaire 2024

4. Name*
5. Email Address*
7. Address*
9. City*
10. State*
11. Zip Code*
13. Phone Number*
14. Date*
    Date

16. - Questionnaire -

18. Do you have a sprinkler system?

    1. Yes
    2. No
    3. Unsure
19. If "yes", Has the PVB (pressure vacuum breaker) been tested?

    1. Yes
    2. No
    3. Unsure
21. 
    

    If "NO", see website for information on how to get my backflow device tested

23. Does the outside hose bibbs have vacuum breakers?

    1. Yes
    2. No
    3. Unsure
24. Do you have a water assisted sump pump?

    1. Yes
    2. No
    3. Unsure
26. Are you the homeowner?

    1. Yes
    2. No
27. If "no", do you rent the home?

    1. Yes
    2. No
29. Self report your type of service (before the meter)
    -- Select One --LeadGalvanizedCopperPVCUnknown

    To help you, scratch the service line with a coin. What color is the area you scratched?

    Lead - shiny silver color
    Galvanized - dull gray color
    Copper - tarnished penny color
    PVC - gray or white color

31. 

33. For additional assistance watch this video (courtesy from the city of Hamilton)

35. If you answered UNKNOWN, 
    The line entering your home has to be confirmed by either scheduling a Water Department Employee for an inspection or as a convenience to you, a photo of the area (along with your address) can be emailed to us at TaylorWater@cityoftaylormi.gov.                       

    TO SCHEDULE AN APPOINTMENT
    Call (734) 287-6550 Option #8 or email your photo to TaylorWater@cityoftaylormi.gov (don't forget your home address)

Leave This Blank:


37. 1. Receive an email copy of this form.
38. Email address

    This field is not part of the form submission.

39. Submit

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