Sample Bottle Order Form

(testing public water supplies)

To request sample bottles for testing of water supplies, please complete and submit the following form, indicating the quantity of bottles needed for each test specified. Bottles include complete instructions for collecting and submitting water samples for testing. Fee information for the various tests is also provided. Questions can be directed to the Lab's mail room at 605-773-3368.

Shipping Information

Name

Title

Water System

Street Address

Mailing Address

City

State

Zip Code

Work Phone Number

FAX number

EPA ID Number

E-mail address

Quantity of Sample Bottles requested

Bacteria - unchlorinated

Bacteria - chlorinated

Nitrate

Lead/Copper

Other (specify test type)

State Public Health Laboratory

Sample Bottle Order Form