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MISSOURI DEPARTMENT OF HEALTH AND SENIOR SERVICES
101 NORTH CHESTNUT STREET, PO BOX 570
MISSOURI STATE PUBLIC HEALTH LABORATORY
JEFFERSON CITY, MO 65101
(573) 751-3334
BACTERIOLOGY PRIVATE WATER TEST REQUEST
TEST REQUESTED
$10 Routine Well (Total Coliform and E.coli)**
Accession Number Barcode
Non-Drinking Dairy Water
(For LAB use only)
Other
No Charge Routine Well (MUST CHECK APPROPRIATE NO CHARGE JUSTIFICATION BELOW)
COLLECTOR / SAMPLE INFORMATION (If different from submitter information)
COLLECTOR LAST NAME, FIRST NAME
DATE COLLECTED (YYYY/MM/DD)
TIME COLLECTED (24 HR FORMAT)
BOTTLE NUMBER
COLLECTION POINT (ex: sink, outside spigot)
COLLECTION LOCATION NAME
COLLECTION LOCATION STREET ADDRESS
CITY
ZIP CODE
STATE
SUBMITTER INFORMATION (RESULTS ARE RETURNED TO THIS ADDRESS)
SUBMITTING FACILITY NAME
PROJECT NAME
SUBMITTER LAST NAME, FIRST NAME
SUBMITTER TELEPHONE NUMBER/EXT
SUBMITTING FACILITY ADDRESS
CITY
STATE
ZIP CODE
ADDITIONAL INFORMATION
COLLECTION LOCATION COUNTY
COLLECTION LOCATION GPS LATITUDE
COLLECTION LOCATION GPS LONGITUDE
COLLECTION LOCATION OWNER TELEPHONE NUMBER
COLLECTION LOCATION OWNER LAST NAME, FIRST NAME
SUPPLY TYPE
Non-Community Public
Community Public
Private Well - Single Family
Private Well - Multi Home
Chill Water
LOCATION TYPE
Child Care Facility
Restaurant
Motel / Resort
Grocery / Convenience Store
USDA Inspected
Non USDA Inspected
Dairy Plant / Farm
LOCATION EST NUMBER
CONSTRUCTION TYPE
SEWAGE DISPOSAL
Drilled Well
Driven Well
Spring
Bored/Dug Well
Other
City-Sewer
On-Site
RESAMPLE AFTER TREATMENT
NO CHARGE JUSTIFICATION
Yes
No
Government
WIC
Foster Care
Head Start
Child Care
USDA / Non USDA Inspected Facility
**A $10 handling fee is required at the time of testing. Failure to pay will result in sample
being discarded without testing.
MO 580-3168 (9-17)
LAB -177