Welcome to our Bottle Request form customized for NY Drinking Water System Operators.


If you have yet to receive a copy of your current permit from the Health Department, please contact them for a new copy


Name:
PWS #:
Company or Organization:
Phone #:
Email:
Mailing Address:
Date to be Delivered/Picked up:
Shipping Method:
Water at Sample Point:
Sample Kits Number of Kits Needed
Coliform - Bacteria:
Total Coliform and e.coli
Lead and Copper:
Pb/Cu
Disinfection By-Products:
THM
HAA
Table Listings:
Table 8B: Primary Inorganic
(Antimony, Arsenic, Barium, Beryllium,
Cadmium, Chromium, Cyanide, Mercury,
Nickel, Selenium, Thallium, Fluoride)
Table 8C: Nitrate, Nitrite
Table 8D: Secondary Inorganic
(Chloride, Iron, Manganese, Silver, Sodium,
Sulfate, Zinc, Color, Oder)
Table 9B/9D: Principle Organic Contaminants
POC's
Table 9C: Synthetic Organic Contaminants
(EPA 504.1, EPA 505, EPA 531.1, EPA 515.4,
EPA 525.2)
Table 10A: Turbidity
Chemical Monitoring:
Radium-226
Radium-228
Gross Alpha
Gross Beta
TOC
Other: Please list under Special Request
Special Request: