Water Testing - Bottle Order Form

Water Providers or Wastewater Companies

This order form is designed for water providers and wastewater companies
for regulatory compliance water testing.

If you are placing an order as a well owner, private citizen, realtor or testing water
from nursing homes, hospitals, hotels, bath houses or spas,
click here to be redirected to your appropriate order form.

Ordering Information

The Laboratory Services Division provides bottles at no cost to customers, for the collection of water samples for testing.

These specially prepared bottles are guaranteed to be free from contaminants, so that your water sample can be tested properly.

If you need additional information about water testing:

Visit our website for testing explanations, pricing and result turnaround times.

Customers sending samples to the lab for water testing can designate "rush"
       testing on their test request form.
        Rush testing prices are double the price of the test.

E-mail the laboratory at: cdphe.lab@state.co.us

Contact the water-testing laboratory at: (303) 692-3048

Click on the links provided for some lab tests on the order form.

Click on the question marks

on this order form for more information.

Customer Information

* Customer Number

New Customer

Current Customer - Do not recall customer number

Current Customer - Customer number(s) provided below

PWSID Number

WP, WT or ENV Number

PRIMARY CUSTOMER ADDRESS

* First Name

* Last Name

Company Name: (if applicable)

* PRIMARY Street Address

Address Line 2

* City

* State

* Zip Code

* Phone Number

2nd Phone Number (if available)

FAX Number

E-mail

(This E-mail entry allows our shipping unit
to respond to your order by E-mail.)

Confirm E-mail & Receive Order Receipt

(Order receipt is sent to this E-mail entry.
If left blank, no order receipt will be sent.)

Business address

Business operating from a residential address

Residential address

*

Pick-Up?
(Allow 2 days for processing your order before picking it up)

Will pick up bottles/kits from Laboratory Services Division

Earliest Date of Pick-up

Map

Ship-To Address

Same as primary customer address above

If different than primary address, provide shipping information below.

First Name

Last Name

Company Name: (if applicable)

Shipments are sent by FedEx and cannot be sent to P.O. Boxes

SHIPPING Street Address

Address Line 2

City

State

Zip Code

Business address

Business operating from a residential address

Residential address

Bill-To Address

Same as primary customer address above

If different than primary address, provide billing information below.

First Name

Last Name

Company Name: (if applicable)

BILLING Street Address

Address Line 2

City

State

Zip Code

Phone Number

E-mail Address

Results-To Address

Same as primary customer address above

If different than primary address, provide address information for sending test results in the spaces below.

First Name

Last Name

Company Name: (if applicable)

RESULTS Street Address

Address Line 2

City

State

Zip Code

Phone Number

FAX Number

E-mail Address

* Indicates Response Required