Private Citizen Water Test Kit Request Form

Private Citizen Request Form

All information is required.

The lab has a 90 day return policy on all kits. This means that those kits not returned within 90 days will be charged the cost of the kit plus postage. Those clients who return their unused kit within 90 days will only be charged for the postage cost in sending it out. If you return your sample for testing, only the analysis fee is charged.

Coliform samples must be collected and mailed the same day. Deliver or mail samples and forms promptly by first class mail or an overnight service, Monday through Thursday. Beware of state and federal holidays. Sample over 30 hours old will not be tested.

Ship to

Full Name Address 1 Address 2 City Zipcode State

Bill to:

Complete if different than ship to address:

Name Street Address City State

Zip

Complete phone field(s) where it is best to reach you:

Phone Number

Mobile Phone Number

Work Phone Number

Email Address

For a Home Loan?

Yes No

For a Foster Home?

Yes No

Type of Kit

Type of Bacteria Kit (leave unchecked if none)

Presence/Absence Numerical Count Bacteria (# of kits you require - leave empty if none) Nitrate (# of kits you require - leave empty if none) Other (# of kits you require and type - leave empty if none) Questions or Comments

Private Citizen Water Sample Test Kit Request Form

Private Citizen Request Form

Ship to

Bill to:

Type of Kit