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2. LEAD FREE ROSEVILLE SUBMISSION FORM

   Please fill out this form to report the material of your water service line.

   If you are having issues with this form, please email the information to sally.ricard@cityofroseville.com.

4. Contact Information
6. First Name (REQUIRED)*
7. Last Name (REQUIRED)*
9. Address 1 (REQUIRED)*
11. Address 2
13. City
14. State
15. Zip Code
17. Home or Cell Phone Number (REQUIRED)*
18. Email Address
20. Water Service Material (REQUIRED)*
    -- Select One --LeadGalvanizedCopperPlasticSteelBrassUnknown/Other

    Please select the pipe material coming into the building.

22. Upload Photos

    If you are unsure of the water pipe material, please upload up to three (3) photos.  No need to provide photos if you are confident about the water pipe material.

24. Photo 1:
26. Photo 2:
28. Photo 3:
Leave This Blank:


30. 1. Receive an email copy of this form.
31. Email address

    This field is not part of the form submission.

32. Submit Submit and Print

* indicates a required field