Water Line Survey Questionnaire

Dear Water Customer:
The U.S. Environmental Protection Agency (EPA) recently issued regulations requiring all public water supply (PWS) systems to develop a Lead Service Line Inventory (LSLI) of both water system owned and your privately owned service lines. Your PWS system must submit this inventory to the Kansas Department of Health and Environment (KDHE) by October 16, 2024.

While these contaminants are not in the source water, they can enter tap water through the corrosion of service line piping and older household plumbing materials. Your water system is sending this survey to all customers asking that you complete and return the form below. We thank you for your cooperation in helping us with this to continue to serve clean and safe drinking water to our customers. Please take a few minutes to complete this questionnaire to the best of your ability and return to the address at the end of the questionnaire.

Additional information on the Lead and Copper Rule and identifying lead pipes and plumbing can be found on the KDHE website at: kdhe.ks.gov/547 or at the EPA Website at: epa.gov/dwreginfo/lead-and-copper-rule

Please submit a separate survey for each structure containing water lines that you own. Even if the structure does not have water service at this time.

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Name *

First

Last

Phone Number *

Property Street Address *

Do you have active water service at the address listed above? *

• Yes
• No

Structure Type *Single Family HomeMulti-Family Home (duplex/quadplex)ApartmentCommercial BuildingIndustrial Facility

Year Built

If you are unsure on the year your home was built you can visit Cherokee County Appraisers website at https://cherokeecountyks.gov/main/departments/appraiser.

What pipe material is the service line pipe entering your house, foundation, or business made of? *LeadLeadCopperGalvanized SteelPVCHDPEPEXASBESTOS CEMENTOTHER NON-LEADUNKNOWN

Materials List (Check all the apply)

Plumbing Pipe Material Examples

Poly/Pex

Copper/Lead

Galvanized Steel

PVC

What year was your service line installed?

This may be the year the structure was built.

What size pipe is the service line entering your house or business? (inches)

What material are the plumbing pipes in your house or business mostly made of? *LeadCopperGalvanized SteelPVCHDPEPEXASBESTOS-CEMENTOTHER NON-LEADUnknown

Plumbing Pipe Material Examples

Poly/Pex

Copper/Lead

Galvanized Steel

PVC

What is the second most common plumbing pipe material in your home or business? *CopperLeadGalvanized SteelPVCHDPEPEXASBESTOS-CEMENTOTHER NON-LEADUNKNOWN

Plumbing Pipe Material Examples

Poly/Pex

Copper/Lead

Galvanized Steel

PVC

How old are the pipes inside your house? *

• Installed before 1989
• Between 1989 and 2014
• After 2014

Do you have a water softener, a whole home water purification system, RO-system, faucet filter or any other treatment device installed in your house or business? *YesNo

If your home or business meets the criteria for lead and copper sampling, would you be willing to participate in this testing? *YesNo

During testing, a Water Supply Employee would bring an empty bottle to your house, provide you with documentation and instructions on collecting the sample, and return the next day for pick up.

Submit