1. Name*:
   
   
2. Phone Number*:
   
   
3. Fax Number:
   
   
4. Email*:
   
   
5. Mailing Address:
   
   
6. City & State*:
   
   
7. Zip:
   
   
8. Best Method of Contact*: Please Select Option: Mail Fax Email Call me first

Project Contact Information (if different than your contact info.):

1. Job Name:
   
   
2. Job Contact:
   
   
3. Job Address:
   
   
4. Job City & State*:
   
   
5. Job Zip:
   
   
6. Job Telephone:
   
   

1. Type of Project: Please Select Option: Single Family Home Apartment Condominium Hotel / Motel Commercial Building Other
   
   
2. Have you experienced: Please Select Option: All below-slab leaks All above-grade (ceiling and walls) leaks Both below and above-grade leaks No leaks so far (skip to step 6)
   
   
3. Have your leaks been: Please Select Option: Hot water leaks only Cold water leaks only Equally hot and cold water leaks Mostly all hot water leaks, a few cold leaks Mostly all cold water leaks, a few hot water leaks No leaks so far
   
   
4. Frequency of leaks: Please Select Option: More than 1 leak per month Less than 6 leaks per year Less than 12 leaks per year
   
   
5. Type of piping material: Please Select Option: Copper Galvanized Steel Plastic Other
   
   
6. Plumbing is routed: Please Select Option: All above-grade Both above & below-grade (buried below-slab)
   
   
7. Do you have samples of the failed pipes available for examination?
   Yes   No
   
   
8. The project has the following characteristics:
   • Number of units:
   • Number of buildings:
     
     
9. Approximate age of the buildings: Please Select Option: Less than 10 years old Between 10 and 20 years old Over 20 years old
   
   
10. Type of hot water system: Please Select Option: Tank Heaters Tube Bundle type boilers Other
    
    
11. Layout of hot water system: Please Select Option: One water heater per residential unit One water heater per building One water heater location for several buildings
    
    
12. If you selected "One water heater location for several buildings", please provide the total number of water heater locations:

Additional Comments:

Note: Please indicate any other job or contact instructions in the above Comments Section.
FOR MULTI-UNIT, CONDOMINIUM, OR COMMERCIAL BUILDINGS PLEASE FAX SITE PLAN MAP TO 619-223-7750