Lead and Copper Sample Collection Request

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Sample Type:

NOTE: If WQP, form 20679 will need to be completed with PWS Information, sample information (Facility ID, Sample Point ID, Sample Location), Name/signature of PWS Rep and date.

Name *

First

Last

Company Name *

PWS Number *

Email *

Phone *

Collection PWS Email

Number of Sites *

Preferred Date to Schedule Collection *

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