Name: Phone:

Address:

Town: Zip:

Billing Address: Town: Zip:

Do you have a current water treatment system in place?: Yes No

If so, check all that apply:
Water Softener: Iron Filter: Acid Neutalizer: Cartridge Filter:
Radon System: Arsenic System: Carbon Filter: UV Light:

Other:

If so, when was it installed:

Who installed it?:

Is your water staining your fixtures?: Yes No

If so, what color is the staining?:
Orange: Black: Blue: Green: Brown:

If you lift off the back of the toilet tank, what color is the water?:

Is your water staining your laundry?: Yes No

Does your water smell?: Yes No

If so, Does it smell like:
Metal: Rotten Eggs: Musty:

How old is your house?:

How many bathrooms?: How many people in the house?:

Do you have a full basement?: Yes No

Is there a floor drain?: Yes No

Do you have a jet pump or a submersible pump?:

What kind of pipes are in the house? (check which one applies):
1/2" Copper: 3/4" Copper: 1" Copper: Plastic/Pex pipe:

Other Comments: