Lead and Cooper Questionnaire

Dear Hennessey Utilities Authority Customer,

The U.S. Environmental Protection Agency (EPA) has recently made changes to the Lead and Copper
Rule (LCR), the law governing the presence of lead and copper in drinking water. These Lead and Copper
Rule Revisions (LCRR) require that all lead service lines and pipes in community water supplies be
identified. Under these revisions, water systems must make an inventory of all service line piping
materials entering and exiting the meter on all services. This inventory is being done so the EPA can
determine how much lead and galvanized piping is in active use.
Hennessey Utilities Authority is asking for your assistance in collecting this data. Please fill out the
information to the best of your knowledge. Any survey not returned will be considered unknown and
may be subject to water testing to determine line composition.

Name When was

Account Number *

When was your home built? *

if no residence, just answer N/A

Do you rent or own your property? *

When was your service line installed, if known? *

Line Material: If you know your material, please indicate below. *

• Lead-Lead is a non-magnetic metal that is dull gray in color is soft and when scratched, produces a shiny silver color.
• Galvanized Steel-Galvanized steel is a magnetic metal that is difficult to scratch and is dull silver in color. Rusts often when buried.
• Copper-Copper is a soft metal, and is a reddish, brown color much like a penny.
• PVC-Polyvinyl Chloride Pipe is a smooth plastic pipe usually white in color.
• HDPE also known as Poly or PEX-High Density Poly Ethylene Pipe is a smooth flexible pipe that is usually white, blue, or black in color.
• Unknown-The customer’s service line material is unknown.
• If unknown, I give permission, to Hennessey Utilities Authority, to excavate a small hole in my yard to verify material composition.

Signature *

Date

Name *

First

Last

Address *

Address Line 1

Address Line 2

City

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