EnviroTestKits® Water Quality Testing
Safe Home® GLYPHOSATE 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:
(Safe Home® GLYPHOSATE Rev: 05-18-19)
Sample Vials
Properly Filled?
P
Sample
Vials
Intact?
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.
ETK-GLY
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
(Turn-Around-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:
GLYPHOSATE
Collection
Matrix
Drinking Water
Lab ID
Received By
Date/Time
Grab
Sample Conditions
Below This Line: Lab Use Only
/
