Request a Water Test Kit

More about lead-in-water-test kits

Contact Info

Fields with an asterisk are required in order to submit your request

First Name

Last Name

Phone

Preferred Language

How did you hear about this testing program?

If you selected "Other" above, please describe how you heard about the program

Is your mailing address different from the address where the sample will be collected?

Yes, my mailing address is different.No

Mailing Address

Where do you want the lead testing kit mailed to?

Mailing Street Address

example: 123 Mill St or PO BOX 456

Mailing City

Mailing State

Mailing Zip Code

Water Sampling Address

Please enter the address where the water sample will be taken.
If you need to multiple sample addresses, you must submit a separate request for each address.

Address Number

example: 501, 400, etc.

Street Quadrant

example: N, NW, NE, etc

Street Name

example: Main, 4th, 82nd

Street Type

example: AVE, ST, DR

Unit Number

example: 23B, A, Apt B, etc

City

State

Zip Code

Comments about your request

Additional Information

Please provide additional information about the location where the water sample will be taken.

Water Provider

Year Structure Built

Please enter a 4 digit year

Pregnant people and/or Children Age 6 and Under in Household?

Check this box if you would like us to call you to discuss any other concerns about lead poisoning