New Customer Environmental Enrollment Form

Date Submitted & Year For Enrollment

Date Submitted & Year For Enrollment

Today's Date *

This request is for enrollment year: *

Identification Information

Identification Information

WSLH PT ID (7 Digits)

Wisconsin Department of Natural Resources ID#

Wisconsin Department of Agriculture, Trade and Consumer Protection ID#

Contact Information of person completing this form

Contact Information of person completing this form

Facility Name *

Contact Name *

Phone *

Example: 123-456-7890

Email *

Shipping Information

Shipping Information

Facility Name *

Contact Name *

Address

Apt, suite, etc.

Country

City

State

Zip code

Phone *

Example: 123-456-7890

Fax

Email *

Billing Information

Billing Information

Check here if same as shipping information

Facility name

Contact name

Address

Apt, suite, etc.

Country

City

State

Zip code

Phone

Example: 123-456-7890

Fax

Send Reports To:

Send Reports To:

Check here if same as shipping information.

Facility Name

Contact Name

Address

Apt, suite, etc.

Country

City

State

Zip code

Phone

Example: 123-456-7890

Fax

Select Type Of Testing Site For This Order

Select Type Of Testing Site For This Order

Select

Other:

Order Form: Potable Water

Order Form: Potable Water

Certification Samples

Quality Control Standards

SDWA Cyanide (Total Cyanide)

PT08160 $48.00

SDWA Cyanide (Total Cyanide)

PT08370 $144.00

SDWA Metals

PT08170 $66.00

(Antimony; Arsenic; Barium; Beryllium; Cadmium; Chromium; Copper; Lead; Mercury; Nickel; Selenium; Sodium; Thallium)

SDWA Metals

PT08380 $198.00

(Antimony; Arsenic; Barium; Beryllium; Cadmium; Chromium; Copper; Lead; Mercury; Nickel; Selenium; Sodium; Thallium)

SDWA Minerals

PT08180 $46.00

(Nitrate as N; Nitrate + Nitrate as N; Fluoride; Sulfate)

SDWA Minerals

PT08390 $138.00

(Nitrate as N; Nitrate + Nitrate as N; Fluoride; Sulfate)

SDWA Nitrate (Nitrate as N)

PT08190 $44.00

(Nitrate as N)

SDWA Nitrate

PT08400 $132.00

(Nitrate as N)

Order Form: Non-Potable Water

Order Form: Non-Potable Water

Certification Samples

Quality Control Standards

BOD/CBOD/COD

PT08000 $50.00

(Biological Oxygen Demand; CBOD; Chemical Oxygen Demand)

BOD/CBOD/COD

PT08200 $150.00

(Biological Oxygen Demand; CBOD; Chemical Oxygen Demand)

Chlorine

PT08010 $47.00

(Total residual chlorine)

Chlorine

PT08210 $141.00

(Total residual chlorine)

Cyanide

PT08020 $48.00

(Total Cyanide)

Cyanide

PT08220 $144.00

(Total Cyanide)

Hardness

PT08030 $44.00

(Hardness [EDTA])

Hardness

PT08240 $132.00

(Hardness [EDTA])

Metals A

PT08040 $66.00

(Aluminum; Barium; Cadmium; Calcium; Chromium; Cobalt; Copper; Hardness; Iron; Lead; Magnesium; Manganese; Nickel; Potassium; Silver; Sodium; Zinc)

Metals A

PT08250 $198.00

(Aluminum; Barium; Cadmium; Calcium; Chromium; Cobalt; Copper; Hardness; Iron; Lead; Magnesium; Manganese; Nickel; Potassium; Silver; Sodium; Zinc)

Metals B

PT08050 $60.00

(Arsenic; Mercury; Selenium)

Metals B

PT08260 $180.00

(Arsenic; Mercury; Selenium)

Metals C

PT08060 $60.00

(Antimony; Beryllium; Molybdenum; Strontium; Thallium; Vanadium)

Metals C

PT08270 $180.00

(Antimony; Beryllium; Molybdenum; Strontium; Thallium; Vanadium)

Metals D

PT08070 $66.00

(Bismuth; Lithium; Silicon; Titanium)

Metals D

PT08280 $198.00

(Bismuth; Lithium; Silicon; Titanium)

Metals E

PT08080 $61.00

(Boron; Tin)

Metals E

PT08290 $183.00

(Boron; Tin)

Minerals

PT08090 $50.00

(Alkalinity CaCO3; Chloride; Conductivity; Fluoride; Sulfate)

Minerals

PT08300 $150.00

(Alkalinity CaCO3; Chloride; Conductivity; Fluoride; Sulfate)

Nitrite

PT08100 $44.00

(Nitrite as N)

Nitrite

PT08310 $132.00

(Nitrite as N)

Nutrients A

PT08110 $50.00

(Ammonia as N; Nitrate as N; Nitrate + Nitrite as N; ortho‐Phosphate as P)

Nutrients A

PT08320 $150.00

(Ammonia as N; Nitrate as N; Nitrate + Nitrite as N; ortho‐Phosphate as P)

Nutrients B

PT08120 $44.00

(Total Kjeldahl nitrogen [TKN]; Total phosphorus)

Nutrients B

PT08330 $132.00

(Total Kjeldahl nitrogen [TKN]; Total phosphorus)

Oil and Grease

PT08130 $63.00

(HEM)

Oil and Grease

PT08340 $198.00

(HEM)

PT08140 $42.00

PT08350 $126.00

Solids

PT08150 $53.00

Total Dissolved Solids [TDS]; Total Suspended Solids)

Solids

PT08360 $159.00

Total Dissolved Solids [TDS]; Total Suspended Solids)

Order Form: Water Microbiology

Order Form: Water Microbiology

Water Microbiology – Certification

PT08410 $296.00

Water Microbiology – Quality Assurance (Two events: March and October)

PT08420 $156.00

Water Microbiology – Quality Assurance (One event: March)

PT08430 $78.00

Water Microbiology – Quality Assurance (One event: October)

PT08440 $78.00

Order Form: Total Price

Order Form: Total Price

Total: Add price of all checked items.

Indicate Method Of Payment

Indicate Method Of Payment

Payment Method

Bill Me: PO# to reference on invoice

VISA/MC: If you wish to pay by credit card, please wait for your invoice for instructions.

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