Clean Water Lab Order Form - Clean Water Labs

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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
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 Country
Phone*
Sample Information
Please select the proper test code, date, and time of collection.
Number of Samples*
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*
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

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*
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

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*
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

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*
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

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*
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

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*
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

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*
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

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*
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

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*
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

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*
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

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.
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Comments
This field is for validation purposes and should be left unchanged.

Clean Water Lab Electronic Order Form

Electronic Order Form Instructions

Sample Information

Additional Sample Information

End of Form

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