Our Lobby is Closed
Due to the recent COVID-19 outbreak, we are closing our lobby to the public and reducing items that go in and out of the lab. In order to protect our staff and the community we require all drop-off clients to fill out an order form online.
Date Format: MM slash DD slash YYYY
CONTACT US TO SET UP AN APPOINTMENT, if you haven't already. Enter your scheduled drop-off appointment date.
Please enter the start of your scheduled drop off time frame.
Electronic Order Form Instructions
1. You must have contacted our office for an appointment before filling out this form.
2. Please fill out the form in its entirety.
3. Select the correct test code. You may have been given specific instructions in an email.
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.
