Water Quality Complaint Form

2. Date
   Date
4. Name
5. Email Address
7. Address
9. City
10. State
11. Zip Code
13. Home Phone Number
14. Mobile
16. Nature of Complaint
    -- Select One --OdorColorTasteOther - add detail @ bottom of form
17. How long has the problem existed?
19. Do you know if there was a recent fire in the area?
    -- Select One --YesNoUnsure
20. Do you know of any road work in the area?
    -- Select One --Yes - On my streetYes - in my neighborhood No Unsure
22. Is the issue with one or multiple faucets?
    -- Select One --OneMultiple
23. What are your pipes made out of?
    -- Select One --LeadCopperGalvanized Pex Mix
25. Do you have any pets? (check all that apply)

    1. Dog(s)
    2. Cat(s)
    3. Fish
    4. Birds
    5. Small Mammals
    6. Reptiles
26. Do you use a water filter?
    -- Select One --Yes - Faucet FilterYes - Filtered Water PitcherYes - Refrigerated Water Filtration LineNo - Straight From The Tap
28. Please choose 3 dates and times that are convenient for us to come and take a water sample. Please note that we are only available during normal business hours.
30. #1
    #1

    #1
31. #2
    #2

    #2
32. #3
    #3

    #3
34. Please provide any additional detail you feel is necessary.
Leave This Blank:


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

    This field is not part of the form submission.

38. Submit

* indicates a required field