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Clean Water Lab Electronic Order Form
You may fill out and submit this form if you forgot to submit a paper form or do not have a paper form.
Drop off Date
*
MM slash DD slash YYYY
Drop-off Time
*
:
Hours
Minutes
AM
PM
AM/PM
Sample Drop Off
*
I dropped the sample off myself
I had some one else drop it off for me
This is a technician collection via CWLab
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.
Client Name
*
First
Last
Email
*
This e-mail address will be used for results transmission and records.
Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Phone
*
Sample Information
Please select the proper test code, date, and time of collection.
Number of Samples
*
1
2
3
4
5
6
7
8
9
10
Please let us know how many samples you would like to submit. (note: Homeowner's package will submit 2 samples)
Sample Location
*
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.
Test Code
*
P/A | E. coli & Total Coliform (Drinking Water)
MPN | E. coli & Total Coliform (Surface Water)
pH & Hardness
Date Sampled
*
MM slash DD slash YYYY
We need to receive samples within 24 hours of collection for Bacteria.
Time Sampled
*
:
Hours
Minutes
AM
PM
AM/PM
We need to receive the samples within 24 hours of collection for Bacteria.
Additional Sample Information
Sample Location 2
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.
Test Code
*
P/A | E. coli & Total Coliform (Drinking Water)
MPN | E. coli & Total Coliform (Surface Water)
pH & Hardness
Date Sampled
*
MM slash DD slash YYYY
We need to receive samples within 24 hours of collection for Bacteria.
Time Sampled
*
:
Hours
Minutes
AM
PM
AM/PM
We need to receive the samples within 24 hours of collection for Bacteria.
Sample Location 3
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.
Test Code
*
P/A | E. coli & Total Coliform (Drinking Water)
MPN | E. coli & Total Coliform (Surface Water)
pH & Hardness
Date Sampled
*
MM slash DD slash YYYY
We need to receive samples within 24 hours of collection for Bacteria.
Time Sampled
*
:
Hours
Minutes
AM
PM
AM/PM
We need to receive the samples within 24 hours of collection for Bacteria.
Sample Location 4
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.
Test Code
*
P/A | E. coli & Total Coliform (Drinking Water)
MPN | E. coli & Total Coliform (Surface Water)
pH & Hardness
Date Sampled
*
MM slash DD slash YYYY
We need to receive samples within 24 hours of collection for Bacteria.
Time Sampled
*
:
Hours
Minutes
AM
PM
AM/PM
We need to receive the samples within 24 hours of collection for Bacteria.
Sample Location 5
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.
Test Code
*
P/A | E. coli & Total Coliform (Drinking Water)
MPN | E. coli & Total Coliform (Surface Water)
pH & Hardness
Date Sampled
*
MM slash DD slash YYYY
We need to receive samples within 24 hours of collection for Bacteria.
Time Sampled
*
:
Hours
Minutes
AM
PM
AM/PM
We need to receive the samples within 24 hours of collection for Bacteria.
Sample Location 6
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.
Test Code
*
P/A | E. coli & Total Coliform (Drinking Water)
MPN | E. coli & Total Coliform (Surface Water)
pH & Hardness
Date Sampled
*
MM slash DD slash YYYY
We need to receive samples within 24 hours of collection for Bacteria.
Time Sampled
*
:
Hours
Minutes
AM
PM
AM/PM
We need to receive the samples within 24 hours of collection for Bacteria.
Sample Location 7
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.
Test Code
*
P/A | E. coli & Total Coliform (Drinking Water)
MPN | E. coli & Total Coliform (Surface Water)
pH & Hardness
Date Sampled
*
MM slash DD slash YYYY
We need to receive samples within 24 hours of collection for Bacteria.
Time Sampled
*
:
Hours
Minutes
AM
PM
AM/PM
We need to receive the samples within 24 hours of collection for Bacteria.
Sample Location 8
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.
Test Code
*
P/A | E. coli & Total Coliform (Drinking Water)
MPN | E. coli & Total Coliform (Surface Water)
pH & Hardness
Date Sampled
*
MM slash DD slash YYYY
We need to receive samples within 24 hours of collection for Bacteria.
Time Sampled
*
:
Hours
Minutes
AM
PM
AM/PM
We need to receive the samples within 24 hours of collection for Bacteria.
Sample Location 9
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.
Test Code
*
P/A | E. coli & Total Coliform (Drinking Water)
MPN | E. coli & Total Coliform (Surface Water)
pH & Hardness
Date Sampled
*
MM slash DD slash YYYY
We need to receive samples within 24 hours of collection for Bacteria.
Time Sampled
*
:
Hours
Minutes
AM
PM
AM/PM
We need to receive the samples within 24 hours of collection for Bacteria.
Sample Location 10
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.
Test Code
*
P/A | E. coli & Total Coliform (Drinking Water)
MPN | E. coli & Total Coliform (Surface Water)
pH & Hardness
Date Sampled
*
MM slash DD slash YYYY
We need to receive samples within 24 hours of collection for Bacteria.
Time Sampled
*
:
Hours
Minutes
AM
PM
AM/PM
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.
Name of Sampler
*
First
Last
Please enter the first and last name of the person who collected the sample.
Acknowledgement
*
I agree
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.
Notes to Our Staff
If you have any special notes or request, please enter them here before submitting the form.
CAPTCHA
Email
This field is for validation purposes and should be left unchanged.
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