Please fill out the client information, including:

  • Client Name (*required): Company or client name
  • Email (*required): contact e-mail
  • Address (*required): Company or client address
  • Project Name (optional)
  • Project Number (optional)
  • P.O. Number (optional)
  • Project Manager (optional)
  • Phone Number (*required)
  • Fax Number (required if results are to be faxed)
  • Sampler Name (*required)
  • Sampler Signature (*required)
  • TAT (Analytical Turn Around Time) (*required): (0 = same day, 1 = 24 hours, 2 = 48 hours, etc., N = normal); circle one or type in field
  • Analysis/Analyses Requested (*required): name of analysis/analyses

For each Sample:

(“Sample No.” is for lab use; please leave blank)

  • Date Sampled (*required): mm/dd/yy or mm/dd/yyyy
  • Time Sampled (*required): 00:00 (military time or indicating am/pm)
  • Sample Description (*required): (you may include your own sample IDs here)
  • Matrix (Water or Other) (*required): Other includes soil, food, juice, etc.
  • Container (Qty., type, Grab/Comp) (*required): number, type of containers
  • Analysis (Check box) (*required): check off analysis/analyses requested for each sample

If using multiple pages, you may indicate so on the top right of the page.

Please sign under Relinquished by (*required) and Received by (*required) as necessary.

Please indicate if your sample is a compliance drinking water sample. Circle Yes or No, then sign and date. (*required)

Special instructions may be indicated on the bottom of the page.

Please contact us if you have any questions.