SUBMIT A FORM

2. 
3. DATE*
   DATE
4. SERVICE LINE MATERIAL SURVEY

   The City of Defiance would like your help in completing this vital survey to document the material of your water service line from the curb box to your house or business. The Ohio EPA requires all state municipalities to verify the pipe materials used on both the customer and city sides of the curb box. Without a completed survey, the state may require us to excavate your service line to verify the material used.

6. First Name*
7. Last Name*
9. Address*
11. City*
12. State*
13. Zip Code*
15. Phone Number*
16. Email Address*
18. TYPE OF MATERIAL ON MY WATER SERVICE LINE*

    Check the line going from the water meter to just outside of your house of business. Based on the appearance, testing, or existing records, please select the appropriate material of your water service line.

    1. Lead
    2. Galvanized Steel
    3. Copper
    4. Plastic
    5. I am unsure. I would like someone from the City of Defiance to assist me in identifying the material.
    6. Other (enter "Other" below)
20. If other, enter here:
22. I HAVE DETERMINED MY SERVICE LINE MATERIAL TYPE as follows:*

    1. I have observed the material and know what it is.
    2. I have been provided some form of documentation of the water service line material.
    3. This is my best guess.
    4. Other (enter "Other" below)
24. If other, enter here:
26. MY HOUSE OR BUSINESS BUILT in one of the following time periods:*

    1. Prior to 1960
    2. 1960 to 1988
    3. After 1988
    4. I am unsure.
28. Please attach a photo of your service line where it enters your home or business. (OPTIONAL)
30. 
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32. 1. Receive an email copy of this form.
33. Email address

    This field is not part of the form submission.

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