Schools and Childcare Facilities Lead Sampling Program Enrollment

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

Facility Name

Please enter the name of the facility.

Address

Please enter the address of the facility.

Contact Name

Please enter the primary contact name of the facility for Lead Copper interest.

Phone Number

Please enter the contact phone number.

Email Address

Please enter the facilities contact email address.

Comments

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

Building name, description, or location

Address or description of building location.

Contact Name

Please enter the contact name for this building if different than above.

Phone Number

Please enter the buildings contact phone number if different than above.

Email Address

Please enter the contact email address for this building if different than above.

Account Number

Optional. If you know the ECWA Service Account number for this building you can enter it here.

Comments

Please add any comments or questions related to this building.

+ Add additional buildings within district/organization

SUBMIT FORM

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