Date Format: MM slash DD slash YYYY
Please let us know who dropped off the sample.
Electronic Order Form Instructions
Use this form if you do not have a paper order form. This form can be used if an order form was not submitted with the sample.
This e-mail address will be used for results transmission and records.
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Sample Information
Please select the proper test code, date, and time of collection.
Please let us know how many samples you would like to submit. (note: Homeowner's package will submit 2 samples)
This is what you write on your sample cup. Please indicate where you collected the sample. Such as, "kitchen faucet", "well head", or "lake 1". Use identifiers you can recognize later.
Date Format: MM slash DD slash YYYY
We need to receive samples within 24 hours of collection for Bacteria.
We need to receive the samples within 24 hours of collection for Bacteria.
Additional Sample Information
This is what you write on your sample cup. Please indicate where you collected the sample. Such as, "kitchen faucet", "well head", or "lake 1". Use identifiers you can recognize later.
Date Format: MM slash DD slash YYYY
We need to receive samples within 24 hours of collection for Bacteria.
We need to receive the samples within 24 hours of collection for Bacteria.
This is what you write on your sample cup. Please indicate where you collected the sample. Such as, "kitchen faucet", "well head", or "lake 1". Use identifiers you can recognize later.
Date Format: MM slash DD slash YYYY
We need to receive samples within 24 hours of collection for Bacteria.
We need to receive the samples within 24 hours of collection for Bacteria.
This is what you write on your sample cup. Please indicate where you collected the sample. Such as, "kitchen faucet", "well head", or "lake 1". Use identifiers you can recognize later.
Date Format: MM slash DD slash YYYY
We need to receive samples within 24 hours of collection for Bacteria.
We need to receive the samples within 24 hours of collection for Bacteria.
This is what you write on your sample cup. Please indicate where you collected the sample. Such as, "kitchen faucet", "well head", or "lake 1". Use identifiers you can recognize later.
Date Format: MM slash DD slash YYYY
We need to receive samples within 24 hours of collection for Bacteria.
We need to receive the samples within 24 hours of collection for Bacteria.
This is what you write on your sample cup. Please indicate where you collected the sample. Such as, "kitchen faucet", "well head", or "lake 1". Use identifiers you can recognize later.
Date Format: MM slash DD slash YYYY
We need to receive samples within 24 hours of collection for Bacteria.
We need to receive the samples within 24 hours of collection for Bacteria.
This is what you write on your sample cup. Please indicate where you collected the sample. Such as, "kitchen faucet", "well head", or "lake 1". Use identifiers you can recognize later.
Date Format: MM slash DD slash YYYY
We need to receive samples within 24 hours of collection for Bacteria.
We need to receive the samples within 24 hours of collection for Bacteria.
This is what you write on your sample cup. Please indicate where you collected the sample. Such as, "kitchen faucet", "well head", or "lake 1". Use identifiers you can recognize later.
Date Format: MM slash DD slash YYYY
We need to receive samples within 24 hours of collection for Bacteria.
We need to receive the samples within 24 hours of collection for Bacteria.
This is what you write on your sample cup. Please indicate where you collected the sample. Such as, "kitchen faucet", "well head", or "lake 1". Use identifiers you can recognize later.
Date Format: MM slash DD slash YYYY
We need to receive samples within 24 hours of collection for Bacteria.
We need to receive the samples within 24 hours of collection for Bacteria.
This is what you write on your sample cup. Please indicate where you collected the sample. Such as, "kitchen faucet", "well head", or "lake 1". Use identifiers you can recognize later.
Date Format: MM slash DD slash YYYY
We need to receive samples within 24 hours of collection for Bacteria.
We need to receive the samples within 24 hours of collection for Bacteria.
End of Form
Please review the form carefully to ensure the information submitted is correct.
Please enter the first and last name of the person who collected the sample.
By checking the box you ( the client) agree to bring the samples indicated to Clean Water Lab during the scheduled time frame. You also acknowledge and accept that Clean Water Lab is not responsible for client errors made during sample collection, transport, and submission.
If you have any special notes or request, please enter them here before submitting the form.
This field is for validation purposes and should be left unchanged.
