City of Fairfield Lead and Copper Survey
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Property Address for which this survey applies (1 per survey) *
Name and phone number of person filling out this form
Property Information *
Required
Property Information - Year Built *
Required
Materials - What material(s) is your service line/pipe  made of? Check all that apply *
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Required
Materials - When was the service line going into your house or business installed? *
Required
Materials - What material(s) are the pipes in your house or business made of? Check all that apply *
Required
Materials - How old are the pipes in your house or business? *
Required
Do you have a water softener or a whole home water purification system or any other point of use device installed in your house or business? *
Required
If you answered yes to question 5, do you have an untreated kitchen or bathroom faucet?
If your home or business meets the criteria for lead and copper sampling, would you be willing to participate in testing? Testing occurs once every three years. During testing a City Employee will bring an empty bottle, instruction on collecting the sample and a brief form to your home or business.  The next morning a City Employee will pick everything up.
Any additional comments relative to this survey?
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