Lead Service Line Replacement Consent Form

Please confirm that you have read the agreement above.*

I acknowledge I have read the agreement above about the Lead Service Line Replacement.

Name*

First NameLast Name

Address of Property*

Street Address

Address 2

Street Address

Street Address 2: (Unit, apartment or suite number if applicable.)

City

Zip Code

Please provide the contact information where you can be reached during normal business hours:

Daytime Phone Number*

Please enter a valid phone number.

Email*

Confirmation EmailConfirm email

Please select if you APPROVE the Lead Service Line Replacement.*

I DO want Denver Water to replace my lead water service line.

Will you be present during the replacement of the lead service line?*

YesNo

Authorized Representative

If you cannot be present during the replacement, please provide the contact information of a representative, at least 18 years old, that you have authorized to provide us with access to your property (optional):

Representative Name

First NameLast Name

Representative Daytime Phone Number

Please enter a valid phone number.

Representative Email

Confirmation EmailConfirm email

Select the applicable option.*

Property ownerAuthorized RepresentativeTenant

Electronic Signatures and Records. Customer consents to the use of electronic signatures. This form may be signed electronically in the manner specified by Denver Water.

Signature of Property Owner, Authorized Representative, or Tenant*

Date*

MonthDayYear

Please verify that you are human*