Schools and Childcare Facilities Lead Sampling Program Interest Form


Please enter all the information on the following form, and press SUBMIT.

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Please enter the name of the facility.
Please enter the address of the facility.
Please enter the primary contact name of the facility for Lead Copper interest.
Please enter the contact phone number.
Please enter the facilities contact email address.
Please add any comments or questions.

Optionally please click/tap the "+ Add..." button below to add as many additional buildings within district/organization as you like.

Additional Building - Remove This Building from list
Address or description of building location.
Please enter the contact name for this building if different than above.
Please enter the buildings contact phone number if different than above.
Please enter the contact email address for this building if different than above.
Optional. If you know the ECWA Service Account number for this building you can enter it here.
Please add any comments or questions related to this building.
+ Add additional buildings within district/organization

SUBMIT FORM Clear Form Cancel