Private customer water testing bottle order form
This order form is for well owners, private citizens and customers, and realtors.

With every order, a requisition form 250, Request for Analytical Services form, will be sent.

PAYMENT FOR WATER TESTING IS DUE AT THE TIME OF WATER SAMPLE SUBMISSION VIA DROP OFF OR MAIL. Fees can be found at www.colorado.gov/cdphe/lab/billinginfo

A submission receipt will be sent to the email provided below. To view testing packages and pricing click on the URL.
https://docs.google.com/spreadsheets/d/1gLXnB_MbF6VfNP_ioerCBrXWs6V7J44qfDfCyuqIvCE/edit?usp=sharing
Email address *
Customer status *
Customer ID (000#####)
This is for if you are a returning customer. Providing your customer ID increases the turnaround time for processing your order. This is not PWSID.
Your answer
Customer/Contact name *
Your answer
Facility or Business name (If applicable)
Your answer
Customer street address *
Your answer
Customer street address II
(Suite, apt, floor, etc)
Your answer
City *
Your answer
State *
(Other state name)
Your answer
Zip code *
Your answer
Customer phone number *
Your answer
Contact fax number
(Only applicable if wanting reports sent via fax)
Your answer
Billing address *
Required
Shipping address (PO Box not accepted) *
Please allow 2 business days for processing.
Required
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