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2. Name
3. Service Address*
5. Service line material*

   1. Plastic
   2. Lead
   3. Copper
   4. Galvanized Steel
   5. Need Assistance from City in determining line material
7. If you need assistance, please provide your phone number for the City to schedule an inspection.
8. Phone number
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10. 1. Receive an email copy of this form.
11. Email address

    This field is not part of the form submission.

12. Submit

* indicates a required field