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15520 Crestwood Dr., Basehor, KS 66007
913-724-7000
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H20 Lead Awareness Survey
Home
H20 Lead Awareness Survey
H20 Lead Awareness
Customer Service Line
Plumbing Survey
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Please fill out this survey to the best of your knowledge. This information is crucial for us to complete our system material evaluation and comply with the U.S. Environmental Protection Agency’s new regulation.
Completed By
*
First
Last
Customer Name
*
First
Last
Date Completed
*
Phone
*
Address
*
Address Line 1
Address Line 2
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State
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Customer Service Line and Plumbing Information
Year House/Building was Built (if known)
*
Customer Side Service Line Install Year
*
Customer Side Service Line Material (water meter to house)
*
-select-
Lead
Copper
Galvanized
PVC
HDPE
Asbestos Cement
PEX
Other Non-lead
Unknown
Customer Side Service Line Size
*
-select-
3/4"
1"
1 1/4"
1 1/2"
2"
3"
6"
9"
Unknown
Other
Other service line size
Building Type
*
-select-
Single Family House
Townhome / Apartment
Business
Other
Do you have any Water Filter, Softener or Water Treatment in your home/business
*
-select-
Yes
No
Unknown
Primary Plumbing Material In Your House:
*
-select-
Lead
Copper
Copper with Lead Solder
PVC
PEX
Other Non-lead
HDPE
Asbestos Cement
Galvanized Steel
Unknown
Secondary Plumbing Material In Your House
*
-select-
Lead
Copper
Copper with Lead Solder
PVC
PEX
Other Non-lead
HDPE
Asbestos Cement
Galvanized Steel
Unknown
What Year Was Your Plumbing Installed (Range):
*
-select-
Before 1989
Between 1989 and 2014
After 2014
Unknown
Do you consent to providing a water sample for testing?
*
-select-
Yes
No
Unknown
If you are selected, a water district employee will bring a sample bottle to your home and then pick it up the next day. There is no cost to the customer.
If you need help with this survey, please call our office at 913-724-7000.
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