New Customer Environmental Enrollment Form

Enrollment Information

Enrollment Information

This request is for enrollment year: *

Identification Information

Identification Information

WSLH PT ID (7 Digits)

Current/previous account ID (if known)

WI DNR ID#

Wisconsin Department of Natural Resources

WI DATCP ID#

Wisconsin Department of Agriculture, Trade and Consumer Protection

Contact Information of person completing this form

Contact Information of person completing this form

Facility Name *

Contact Name *

Phone *

Example: 123-456-7890

Email *

Type Of Testing Site For This Order

Type Of Testing Site For This Order

Select Type

Indicate "Other" type of testing here

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

Order Form: Potable Water

Order Form: Potable Water

SDWA Cyanide

Certification Item#: PT08160 - Price: $50.00

QC Standards Item#: PT08370 - Price: $150.00

SDWA Metals

Certification Item#: PT08170 - Price: $69.00

QC Standards Item#: PT08380 - Price: $207.00

SDWA Minerals

Certification Item#: PT08180 - Price: $48.00

QC Standards Item#: PT08390 - Price: $144.00

SDWA Nitrate

Certification Item#: PT08190 - Price: $46.00

QC Standards Item#: PT08400 - Price: $138.00

Order Form: Non-Potable Water

Order Form: Non-Potable Water

BOD/CBOD/COD

Certification Item#: PT08000 - Price: $52.00

QC Standards Item#: PT08200 - Price: $156.00

Chlorine

Certification Item#: PT08010 - Price: $49.00

QC Standards Item#: PT08210 - Price: $147.00

Cyanide

Certification Item#: PT08020 - Price: $50.00

QC Standards Item#: PT08220 - Price: $150.00

Hardness

Certification Item#: PT08030 - Price: $46.00

QC Standards Item#: PT08240 - Price: $138.00

Metals A

Certification Item#: PT08040 - Price: $69.00

QC Standards Item#: PT08250 - Price: $207.00

Metals B

Certification Item#: PT08050 - Price: $62.00

QC Standards Item#: PT08260 - Price: $186.00

Metals C

Certification Item#: PT08060 - Price: $62.00

QC Standards Item#: PT08270 - Price: $186.00

Metals D

Certification Item#: PT08070 - Price: $69.00

QC Standards Item#: PT08280 - Price: $207.00

Metals E

Certification Item#: PT08080 - Price: $63.00

QC Standards Item#: PT08290 - Price: $189.00

Minerals

Certification Item#: PT08090 - Price: $52.00

QC Standards Item#: PT08300 - Price: $156.00

Nitrite

Certification Item#: PT08100 - Price: $46.00

QC Standards Item#: PT08310 - Price: $138.00

Nutrients A

Certification Item#: PT08110 - Price: $52.00

QC Standards Item#: PT08320 - Price: $156.00

Nutrients B

Certification Item#: PT08120 - Price: $46.00

QC Standards Item#: PT08330 - Price: $138.00

Oil and Grease

Certification Item#: PT08130 - Price: $69.00

QC Standards Item#: PT08340 - Price: $207.00

Certification Item#: PT08140 - Price: $44.00

QC Standards Item#: PT08350 - Price: $132.00

Solids

Certification Item#: PT08150 - Price: $55.00

QC Standards Item#: PT08360 - Price: $165.00

Order Form: Water Microbiology

Order Form: Water Microbiology

Water Microbiology

Certification Item#: PT08460 - Price: $308.00

Quality Assurance Event 1 and Event 2 Item#: PT08420 - Price: $162.00

Quality Assurance Event 1 only Item#: PT08430 - Price: $81.00

Quality Assurance Event 2 only Item#: PT08440 - Price: $81.00

Other Environmental Samples

Other Environmental Samples

Survey Validated Samples and Rapid Response PT

Customers wanting to order Survey Validated Samples or Rapid Response PT please provide order information from WSLH PT coordinator in the field below.

Order Total

Order Total

Order Total

Add price of all checked items

Payment Information

Payment Information

Purchase Order (PO#) - optional

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

Verification

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