Matrix
Drinking Water
Lab ID
Received By
Date/Time
Not Intended for
Regulated Reporting
General Public Chain of
Custody
Please Read Important Instructions on the Reverse Side of this Form
*All relevant fields must be completed accurately, fully and legibly.
Please register your sample online and place your
ORDER NUMBER below:
* Home Phone Number:
* Cell Phone Number:
*Client's Last Name:
Safe Home®
ARSENIC
Collection
Grab
ETK-AS-ICPMS
7 - 10 Business Days
(TAT starts the first business day
following the day of receipt of this
sample at the Madison, IN lab)
*Date
*Location/Description Where Sample
Was Taken
*Time
(Safe Home® ARSENIC Rev: 05-21-19)
Sample Vial
Properly Filled?
P
Sample
Vial
Intact?
Sample Conditions
(Turn-Around-Time)
PLEASE READ AND FOLLOW THE INSTRUCTIONS CLOSELY ON THE REVERSE
SIDE OF THIS FORM FOR YOUR DRINKING WATER SAMPLE COLLECTION
AND RETURN SHIPPING. MAKE SURE TO PROPERLY REGISTER THIS TEST KIT
ONLINE AS DIRECTED.
Below This Line: Lab Use Only
EnviroTestKits® Water Quality Testing
Safe Home® ARSENIC Drinking Water Test Kit
Account Number: 4000
*Sample Collection
Information
(Testing conducted by - Environmental Laboratories, Inc., Madison, IN
*Client Information: (Please Print)
*Address:
*Client's First Name:
*City, State, Zip:
TEST NAME
*E-mail Address:
-
1
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