County
Section
Sampling Point
Township
Bathroom Sink
Other (List here):
Address
Sta
te
Site Code/
Permit Number
FOR LAB USE
ONLY
REQUEST FOR WATER ANALYSIS
AM
PM
Date Collected Time Collected
Zip
State
Zip
Zip
State
City
Phone Number
City
Billing Name
Test
Test Request Instructions
Check
Code
Unit
Number
Test Description
Fee
B
30
$16.00
Total Coliform/E. coli
R*
32
$18.00
CAS
36ME
$18.00
CCUB
36CC
$26.00
CPB
36ME
$18.00
CXVO*
36VO
$100.00
CXTM*
36VO
$175.00
1. Check box for test code request.
2. Check container label to ensure correct sample
container. Only EGLE containers are accepted.
3. Enter additional test code, sample container and fee.
See Testing Fee schedule, Form EQP2301.
4. Add total of all fees.
5. Sample units 30, 32 and 33 MUST be dropped off at
the laboratory by Friday 3:30PM
6. See reverse side for sample collection instructions.
CXHA*
36HA
36PT
CXPT
*
36HB
*
This test code requires thermal preservation and
should be returned to the laboratory within 24 hours.
36
LP
Enter additional test
code, sample container
and fee from Testing Fee
Schedule here
ºC
No
Complete all parts of this form legibly in ink to ensure your sample is accepted for testing.
Does this sample
contain chlorine?
Yes
No
REPORT RESULTS TO
0 – Routine monitoring
1 – Real Estate Transaction
2 – Repeat Sample
3 – Repair/New Well
5 – Water Quality Problem
9 – Other
0 – Single Family Dwelling
1 – Type 1 (25 or more residents year round)
2 – Type 2 (25 or more persons 60 days or
more per year)
3 – Type 3 (All other public supplies)
8 – Swimming Pool/Spa
9 – Other
1 – Public System Well
2 – Public System Surface Water
3 – Untreated Public Distribution
4 – Treated Public Distribution
5 – Untreated Private Well
6 – Treated/Softened Private Well
7 – Pressure Tank/Plant Tap
9 – Other
EQP2300 05/2024
Total of all fees
***FOR LAB USE ONLY***
Sample Receipt Temperature:
Received on Ice within 24 hours:
Yes
Do NOT test my sample(s) unless all requirements of the Safe Drinking Water Act are met. If you do not check this box,
your sample will be tested. Only samples and results meeting all requirements of the Safe Drinking Water Act will be
accepted for compliance by the State of Michigan. All other results may be used for informational value only.
SAMPLE COLLECTION INFORMATION
Water Supply/Busine
ss or Home Owner
WSSN or
Pool ID
Enter Selection
Enter Selection
Enter Selection
Kitchen Sink
City
Check here if billing name/address is same as report results to
name/address.
Billing Address
BILLING INFORMATION
Send Report to E-mail
Address
Name
Well/
Source Number
EGLE Drinking
Water Lab Acct #
TESTING INFORMATION
Submit White Copy With Sample - Keep Yellow Copy For Your Records
$
$
$
$
Sample Collector's Name
CXHB*
CXLP*
Disinfection Byproducts Rule
(TTHM & Haloacetic Acids)
$1
25.00
$120.00
$120.00
Automated Partial Chemistry
Arsenic
Lead/Copper for corrosion
(first draw sample)
Lead
Volatile Organic Compounds
Pesticides
Herbicides
Carbamates
NN*
32
$17.00
Nitrate and Nitrite
Print Form
Reset Form
You will be invoiced upon analysis completion.
1 Follow These General Sample Collection Instructions for collecting your sample(s)
2
These sample containers may contain a chemical preservative in liquid, powder or tablet form indicated on the container label. Use
caution when
collecting samples. * These sample containers require temperature preservation and should be returned to the laboratory within 24
hours.
1. Turn the cold water tap on full flow and allow the water to run for ten minutes.
2. Reduce the flow to avoid splashing, and remove the sample container cap.
3. Carefully fill the container to the base of the neck or the fill line on the sample container if indicated, and replace the sample container cap. Unit 30
fill the container between the 100 mL and MAX fill lines on the sample container and replace the sample container cap. Return within 24 hours.
36TO*, 36EN*
These sample containers contain a chemical preservative in liquid or powder form indicated on the container label. Use caution when collecting
samples. *These sample containers require temperature preservation and should be returned to the laboratory within 24 hours.
1. Turn the cold water tap on full flow and allow the water to run for ten minutes.
2. Reduce the flow to avoid splashing and remove the sample container cap.
3. Carefully fill the vial
until water rounds at the top,
and replace the sample container cap.
4. Invert the vial. If any air is present in the vial, remove the sample container cap, carefully add additional sample until water rounds at the top,
and replace the sample container cap. Repeat
this step if necessary until no air is present in the vial.
36VO*, 36VO-NP*, 36VO-MEE*
These sample containers may contain a chemical preservative in powder form indicated on the container label. Use caution when collecting
samples. *These sample containers require temperature preservation and should be returned to the laboratory within 24 hours.
1. Turn the cold water tap on full flow and allow the water to run for ten minutes.
2. Reduce the flow to avoid splashing and remove the sample container cap.
3. Carefully
fill the vial half full and add 8 drops of preservative from the provided dropper bottle. Continue filling the vial until water rounds at the top
and replace the sample container cap.
4. Invert the vial. If any air is present in
the vial, remove the sample container cap, carefully add additional sample until water rounds at the top, and
replace the sample container cap.
Repeat this step if necessary until no air is present in the vial.
36CNa*
This sample container contains a chemical preservative and also includes a dilute preservative to be added. Use caution when collecting
samples. *These sample containers require temperature preservation and should be returned to the laboratory within 24 hours.
1. Turn the cold water tap on full flow and allow the water to run for ten minutes.
2. Reduce the flow to avoid splashing and remove the sample container cap.
3. Carefully fill the container to
approximately one inch below the top. Cap and invert to mix.
4. Remove the sample container cap, carefully add the included dilute preservative from the dropper bottle, replace the sample container cap, and invert
to mix.
36CC
These sample containers do not contain a chemical preservative.
Allow the water to sit undisturbed for at least six hours. Do not flush the sample tap prior to sample collection. Do not remove attachments such as
aerators.
1. Remove the sample container cap and place the sample container directly under the sample tap.
2.
3
UPS – FedEx
Michigan EGLE Drinking Water Laboratory
3350 N. Martin Luther King Jr. Blvd
Lansing, MI
48906
Ship Monday – Thursday to receive by Friday
SAFETY DATA SHEETS (SDS)
FOR PRESERVATIONS AVAILABLE
UPON REQUEST.
4
Health Department contact information. Results will be sent to the Health Department for the County entered on the front of this form.
Please allow up to 7-10 business
days for your sample test result(s).
Call your Local County Health Department for an interpretation of your sample test result(s). See your sample test report for your Local County
For additional information visit the Michigan EGLE Drinking Water Laboratory at michigan.gov/eglelab
REQUEST FOR WATER ANALYSIS INSTRUCTIONS
Follow These Specific Sample Container Collection Instructions for collecting your sample(s)
30, 36ME, 32*, 33*, 36AC*, 36CN*, 36HA*, 36HB*, 36LP*, 36PT*
Return samples with this completed form to the Michigan
EGLE Drinking Water laboratory within 24 hours of collection where possible using any
provided frozen ice packs and cooler. Additional ice may be required to meet temperature preservation requirements where samples are not received
by the laboratory within 24 hours of collection. Some samples have shorter testing hold times and must be returned to the laboratory sooner.
Select a clean cold water tap and remove attachments such as aerators prior to sample collection unless otherwise specified.
Do not open the sample container until immediately prior to sample collection.
Do not touch the inside of the sample container or container cap.
Do not rinse the sample container with sample.
Freeze ice packs if provided for a minimum of 24 hours prior to sample collection.
Sample Drop Off
You must call in advance to drop your
samples off. Call 517-335-8184
Michigan EGLE Drinking Water Laboratory
3350 N. Martin Luther King Jr. Blvd.
Lansing, MI 48906
Monday – Thursday 8:00AM to 4:30PM
Friday - 8:00AM - 3:30PM
Turn the water on full flow, carefully fill the container to the base of the neck, and replace the sample container cap.
EQP2300 05/2024
Sample Testing and Your Results
Closed Weekends and Holidays
Return Your Sample(s) and completed form(s)to the Michigan EGLE Drinking Water Laboratory
using one of the methods below:
