2. Lead & Copper Sampling Interest Form
   Please complete this form if you would like for your water to be sampled and tested as a part of our Lead and Copper Sampling program.
4. First Name*
5. Last Name*
7. Street Address*
8. City*
9. Zip Code*
11. Contact Phone Number*
12. Contact Email Address
16. Sampling Sites must be single family structures that meet at least ONE of the following Criteria:
    • Tier 1: Single Family Structures that contain copper pipes with lead solder constructed between 1983-1988
    • Structures served by a lead service line or those that contain lead plumbing
18. Does your plumbing meet at least one of the criteria listed above?*
    -- Select One --YesNo

    If "no" is selected, your address is not eligible for this program and this form submission will result in no further action.

22. Acknowledgement*

    1. I agree to allow The City of Edmond to submit the information provided on this form to the Oklahoma Department of Environmental Quality (ODEQ) for approval as a sample site.
24. Next Steps
    If your residence is approved by ODEQ, you will be contacted by the City of Edmond’s Water Resources Department prior to the annual sampling event. Laboratory personnel will do a visual inspection to confirm the plumbing meets the stated criteria. Details on what can be expected during the sampling event can be found HERE.
Leave This Blank:


26. 1. Receive an email copy of this form.
27. Email address

    This field is not part of the form submission.

28. Submit

* indicates a required field