Water Problem Checklist
Sample Identify (Check)
- Untreated COLD Tap Water
- Cold softened water
- Hot softened water
- Filtered by residential equipment other than softener
Source of Water (Check)
- Private well
- City, municipal or community supply
- Surface supply (river, lake, etc.)
Color of Water When Drawn (Check)
- Clear, colorless
- Yellow, red, brown, or rusty
- Black or gray
- Dirty, sandy, silty
Does Water Have Odor? (Check)
- Yes — sulfur, rotten egg or sewer in cold tap water
- Yes — sulfur or rotten egg taste in hot water only
- Yes — other than above
- No
Does Water Have a Bad Taste? (Check)
- Yes — sulfur, rotten egg or sewer in cold tap water
- Yes — sulfur or rotten egg taste in hot water only
- Yes — other
Does Water Stain? (Check)
- Yes — Yellow, red, brown or rusty
- Yes — Black or gray
- Yes — Blue or green
- No
My Plumbing is: (Check)
- Copper
- Galvanized
- Plastic
- Mixed — copper and galvanized and/or plastic
- Mixed — copper and plastic or galvanized and plastic
Number of People in Home _______________
I. Source of Sample (Check)
- Home — own
- Home — rent
- Apartment
- Other
Equipment Currently in Use (List)___________________
Date sample taken_________
COMPANY NAME__________________
Address____________________________
Telephone #______________
Customer Name___________________
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