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2. Collector/Sample Information (results are returned to this address)
4. Date and Time Collected*
   Date and Time Collected

   Date and Time Collected
5. Bottle Number*
7. Collector First Name*
8. Collector Last Name*
10. Email Address*
11. Phone Number*
    Include Area Code
13. Collection Location Street Address*
14. County*
16. City*
17. State*
18. Zip Code*
20. Owner Information (if different from collector information)
22. Is the owner contact information different from the above?*

    1. Yes
    2. No
24. Owner First Name
25. Owner Last Name
27. Email Address
28. Phone Number

    Include Area Code

30. Owner Street Address
32. City
33. State
34. Zip Code
36. Additional Information
38. Chemical Test Types
    Select 1 or more chemical test types. There is an $8 fee for each chemical test.
40. Nitrates
41. Quantity
    -- Select One --01
42. Nitrates
    Nitrates
43. Shipping Cost
45. Taxable
47. Sulfates
48. Quantity
    -- Select One --01
49. Sulfates
    Sulfates
50. Shipping Cost
52. Taxable
54. Chlorine
55. Quantity
    -- Select One --01
56. Chlorine
    Chlorine
57. Shipping Cost
59. Taxable
61. Iron
62. Quantity
    -- Select One --01
63. Iron
    Iron
64. Shipping Cost
66. Taxable
68. Hardness
69. Quantity
    -- Select One --01
70. Hardness
    Hardness
71. Shipping Cost
73. Taxable
75. Location

    1. Private Home

    1. Dairy

    1. Other
76. Other Location
78. Supply Type*

    1. Non-Community Public
    2. Community Public

    1. Private Well - Single Family
    2. Private Well - Multi Home
79. Sewage Disposal*

    1. City-Sewer

    1. On-Site
81. Construction Type*

    1. Drilled Well

    1. Other
82. Other Construction Type
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83. Calculate Totals Proceed to Checkout

* indicates a required field