WATER PANEL ORDER FORM

If you are in the greater Reno, Carson, Fallon, Minden or Gardnerville area of Northern Nevada and require a water potability test (Water Panel) for your domestic well water, please fill out the form below.

Once the form is submitted, we will contact you and schedule your water pick-up based on the information you provide.

(If you have questions regarding our pickup and testing service, please use the contact form on our contact page or call us.)

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Company

Address

City

State

Zip

Contact Name *

Contact Phone

Contact Email *

If the billing information is different than the Reporting Information above, select the checkbox and fill in the form fields…

• ENTER BILLING INFORMATION

BILLING INFORMATION

Who’s going to receive the invoice?

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Company (Billing)

Address (Billing)

City (Billing)

State (Billing)

Zip (Billing)

Contact Name (Billing) *

Contact Phone (Billing)

Contact Email (Billing) *

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PREFERRED SAMPLE PICK-UP DATE & TIME

When is the best date and time for us to pick-up the sample?

Preferred Pick-Up Date

Preferred Pick-Up Time

PREFERRED SAMPLE RESULTS DATE & TIME

When is the best date and time for you to receive the sample results?

Preferred Results Date

Preferred Results Time

SAMPLING SITE INFORMATION

House Occupied

• Yes

Is the home occupied?

Site Contact Name *

Name of contact to access house to sampling.

Site Contact Phone *

Site Contact Email

SAMPLE ONE INFORMATION

SAMPLE 1 IDENTIFICATION *

By what name do you want to identify this sample as?

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Requested Analysis – Sample 1

• Water Panel
• Retest
• Other…

Retest – What analytes do you need retested?

We offer one free retest for all analytes that failed (were above EPA limits) on your original water test. There is no cost for the re-analysis of the sample and the standard 5-day turnaround applies. Note: There will be a cost if if the laboratory needs to pick-up the sample and/or you need your retested results sooner than the standard 5-working day turnaround.

What Analysis Are Your Requesting?

Where do you request that Sample 1 is to be taken from? *

• Kitchen Sink
• Well Head
• Outside Spigot
• Other…

Where was the water sample taken from?

Please describe other samplinging location…

If there is a filter system, please select filter type for Sample 1: *

• Reverse Osmosis
• Water Softener
• Carbon
• Iron/Manganese
• Other…
• Don’t Know
• None

What kind of filter system is the water sample treated with? (If applicable.)

Please describe other filter system…

DO YOU HAVE A SECOND SAMPLE?

• YES, IF HAVE A SECOND SAMPLE.

Enter information about another sample…

SAMPLE TWO INFORMATION

SAMPLE 2 IDENTIFICATION *

By what name do you want to identify this sample as?

DO YOU HAVE A THIRD SAMPLE?

• YES, IF HAVE A THIRD SAMPLE.

Enter information about another sample…

SAMPLE THREE INFORMATION

SAMPLE 3 IDENTIFICATION *

By what name do you want to identify this sample as?

DO YOU HAVE A FOURTH SAMPLE?

• YES, IF HAVE A FOURTH SAMPLE.

Enter information about another sample…

SAMPLE FOUR INFORMATION

SAMPLE 4 IDENTIFICATION *

By what name do you want to identify this sample as?

Submit