Private Citizen Request Form

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.

Ship to


Bill to:

Complete if different than ship to address:


Complete phone field(s) where it is best to reach you:

Phone Number

Mobile Phone Number

Work Phone Number


For a Home Loan?

For a Foster Home?

Type of Kit

Type of Bacteria Kit (leave unchecked if none)