Public Water Supplies Request Form

Public Water Supplies

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.

Requested By

NE Account Number (example: NE3xxxxxx) Name of Person Requesting Kit

Fax Number

Mobile Phone Number

Work Phone Number

Email Address

Ship to

Full name of person receiving the kit(s) Address 1 Address 2 City Zipcode State

Type of Kit

Bacteria Kit Type (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