Owner of Property Sampled: Phone:
Address: City: State: Zipcode:
Mail Results To: Attn: Phone:
Address/City/Zip: Fax:
q Pre-paid q Business Account Billing Information:
Name: Business:
Address: Address:
Phone: Phone: Fax:
Attn:
Date/Time Sample Collected:_____/_____/_____ at ______(am / pm) Collected by:______
Sampling Point (well, kitchen…) Depth of well:
Well Type (circle one) Sandpoint Drilled Unknown New Other______
Water Type: (circle one) Conditioned Raw Unknown Other______
Which analysis would you like completed? q Bacteria Series $20.00 q Nitrogen Series $20.00
q Nitrate Nitrogen & Total Coliform Bacteria Package $30.00 q *Arsenic $25.00 q *Fluoride $12.00
q Nitrate Nitrogen $15.00 q *Lead $25.00 q *Hardness $27.00
q Total Coliform Bacteria $15.00 q *Iron $20.00 q Other
**Requires additional sample container and alternate collection procedures (please refer to reverse side of this worksheet)**
After collection of sample, mail or deliver sample to:
RMB Environmental Laboratories, 22796 County Hwy 6, Detroit Lakes, MN 56501-7002
If mailing the sample, place the sample in a mailing carton with enough packing to avoid sample container damage. Mail samples directly from the post office Monday through Wednesday to ensure proper delivery. Check with your postmaster for proper mailing instructions. Mail is delivered to the lab at approximately 10:00 a.m. Samples may be delivered directly to the laboratory during receiving business hours: Monday through Thursday, 8 a.m. to 5 p.m.; Friday, 8 a.m. to 1 p.m. Collect the water sample the same day that it is to be delivered to the lab. When this is not possible, keep the sample cold during transportation and storage.
Standard turnaround time for the Nitrate Nitrogen and Total Coliform Bacteria analyses is 3 working days. Reports will be mailed to the address indicated within 3 working days after sample receipt by the laboratory. Standard turnaround time for additional analyses is 7-10 working days.
Lab Use Only
q Rcvd same day as collected q Rcvd on Ice q Temp Blank ____ oC q Rcvd in good condition Chlorine Check: Absent Present
Sample Received on ______at ______Rcvd by: q Check $______#______q Cash $______
TC: Date/Time:______q Colisure: Absent______Present______
E. coli: Absent______Present______
NO3: Date/Time:______mg/L Other:______
Water Sample Collection Instructions
1. Water sample collection should occur as close to the well as possible, using a point in the water system that is regularly used.
2. To ensure the sample best represents the groundwater source the sample should be collected at a location before the water is treated by a water softener, iron filtration unit, or water heater. If this is not possible, bypass the water softener.
3. Remove all aeration devices (screen) from the faucet.
4. Flame the faucet (only if it is solid metal) until thoroughly heated (approx. 1 minute) by using a small propane torch, a butane cigarette lighter, or a candle (do not use matches to heat faucet). If you are not able to flame the faucet, thoroughly disinfect the faucet opening with rubbing alcohol.
5. Run the cold-water tap for a minimum of 5 minutes.
6. Collect the water sample using the sterile plastic bottle. The bottle is sterile until opened. Take great care not to touch the inside of the bottle or cap. Fill the sample container completely full and tightly close the lid.
7. Fill out the information form (on back), and fasten to the bottle with the rubber band.
**Collect and ship the sample to ensure its arrival at the laboratory within 30 hours of collection. Samples which are received after the 30 hour holding time will be considered void, and you will be asked to re-sample.
1. Collect the sample in a 1 liter polyethylene bottle supplied by the laboratory.
2. Collect the first water released from the faucet after the water has been sitting in your pipes for a minimum of 6 hours. It is recommended to collect your sample first thing in the morning. Do not flush the water lines prior to sample collection.
3. Completely fill the bottle in order to collect a representative sample.
4. Fill out the information form (on back) and fasten to the bottle with the rubber band
5. Return the sample as soon as possible to RMB Environmental Laboratories for immediate preservation.
1. Water sample collection should occur as close to the well as possible, using a point in the water system that is regularly used.
- To ensure the sample best represents the groundwater source the sample should be collected at a location before the water is treated by a water softener, iron filtration unit, or water heater. If this is not possible, bypass the water softener.
3. Run the cold-water tap for a minimum of 5 minutes before collecting the sample in the polyethylene bottle supplied by the laboratory.
4. Completely fill the bottle and tightly close. Fill out the information form (on back) and fasten to the bottle with a rubber band. Return the sample as soon as possible to RMB Environmental Laboratories for immediate preservation.