MANDATORY WATER ANALYSIS INFORMATION
Submitted By:
Company/Name
Address:
City
State Zip
County
      Phone  Ext
  Fax Fax Report?
  Email address Email Report?
   
Are you a Public
Water Supply?
  		Yes No
  If Yes, state
PWS ID#
 
Sample Type Routine (RP) Report (RP) Special (SP)
Sample Markings Well Depth: Date (mmddyy)
Water Chlorinated? Yes No Sampling Point: Time (example, 3:30p, 15:30)

REQUESTED ANALYSES
ANALYTICAL COMBINATIONS:
1-W* (20.00) Bacteria (coliform) and Nitrates
2-W* (25.00) Bactera (coliform), Nitrates, Sulfates & pH
3-W* (30.00) DOMESTIC SUITABILITY: Bacteria (coliform), Nitrates, Sulfates, pH, Total
        Hardness (Ca and Mg)& Total Dissolved Solids
4-W* (30.00) LIVESTOCK SUITABILITY: Nitrates, Sulfate, pH, Total Hardness (Ca and Mg), Sodium,
        Chlorides and Total Dissolved Solids
Iron Copper Manganese Zinc         analyzed with any of above combinations ($8.00 each)
COMPLETE MINERAL ASSAY ($35.00) Calcium, Phosphorus, Potassium, Magnesium, Zinc, Manganese, Copper, Iron,
        Cobalt & Sodium
       with 1-W*, 2-W*, 3-W* or 4-W ($30.00)
       individually ($10.00 each, Please Mark) Calcium Phosphorus Potassium Magnesium
                Zinc Manganese Copper Iron Cobalt Sodium

Sulfur Boron Silicon
        with Complete Mineral Assay ($10.00 each)
        individually ($12.00 each)
Molybdenum ($12.00)
INDIVIDUAL ANALYSIS:
Alkalinity ($12.00) pH ($7.00)
Bacteria (coliform) (MPN)* ($14.00) Sulfates ($14.00)
Chloride: Alone ($12.00)

with other water assays ($8.00)		 Total Dissolved Solids ($10.00)
Total Hardness ($14.00) (Ca & Mg)
Nitrates ($12.00) Total Suspended Solids ($10.00)
ADD 6% IOWA SALES TAX TO ALL ITEMS.

*Requires sterile bottle
Sample Size:   6-8 oz. or more
Bacterial analysis:
Public Water Supply samples must not be more than 24 hours old
Private water supply samples must not be more than 36 hours old
See our sampling instructions for more details.

 Signature:
Print Name:

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