Kent County Regional Laboratory Request for Water Analysis
700 Fuller Ave NE, Grand Rapids, MI 49503 616-632-7210 www.accesskent/health/laboratory.htm
Issued Under Authority of P.A. 368, 1978
Collection instructions on back
Fee MUST be paid or billing information provided prior
to testing
*indicates required information
*Sample Source Code:
*Sample Purpose Code:
*Sample Point Code:
0- Single family dwelling
1- Type I (Community, apartment, subdivision, mobile
home park, etc. with 25 or more residents year round)
2- Type II (School, industry, restaurant, office etc. serving
25 or more persons60 days or more per year)
3- Type III (All other public supplies: duplex, small office)
7- Surface Water- includes bathing beach and
wastewater discharge
8- Pool or Spa
0- Routine testing
1- Real estate transaction
2- Repeat sample
3- Construction or New Well
5- Water Quality Problem
9- Other
1- Public System Well
2- Public System Surface Water
3-Untreated Public Distribution
4-Treated Public Distribution
5- Untreated Private Well
6- Treated Softened Private Well
7- Pressure Tank/Plant Tap
9- Other
1- Kitchen tap 9-Drinking Fountain
2- Bathroom tap 10. Milk House
3- Sample tap 11. Surface Water______________________
4- Outside tap 12. Other______________________
5- Well head
6- Pool
7- Spa
8-Pressure Tank
LAB USE ONLY
Check #:
Cash:
CC:
Amount received:
Initials:
Temperature:
Sample Point Bacteria:
PLEASE CHECK THE TEST(S)
REQUESTED
Fees As
of
04/01/16
Drinking Water Bacteria (Total Coliform)
$16.00
Swimming Pool Bacteria (Total Coliform)
$16.00
Pond, Lake, Stream, or other Surface water
Count for Bacteria
$19.00
Automated Partial Chemistry:
Hardness, Sulfate, Iron,
Nitrate, Nitrite, Fluoride, Chloride, and pH
$20.00
Lead
$18.00
Arsenic
$18.00
Lead & Copper (Corrosion control)
$26.00
Does this sample contain
chlorine? Please check:
____ Yes
____ No
Report Results To: Fill in Information Below
*Name:
*Phone:
*Street Address:
*City:
*State:
*Zip Code:
Is the billing address the same? YES or NO
If no, please provide in space below.
Samples received after the EPA specified hold times or without adequate thermal preservation will not be tested.
Those samples will receive a report documenting the samples were not tested and the fee refunded.
Please Provide Billing Information Below.
Name:
Phone:
Street Address:
City:
State:
Zip Code:
THIS AREA IS REQUIRED BY THE EPA AND MUST BE FILLED OUT!
*Collection Location (Business/Owner name)
*Name of Collector:
*Street Address:
*Date Collected:
*City:
*County:
*Time Collected:
*Township:
Well #:
WSSN /Pool #
Site Code:
Please check box if sample was chilled at time of collection
Collector Code: _____
0-County Personnel 6-MDA
1-Water Supply Operator 9-Other
2-MDEQ
3-Private Citizen
5-MDNR
700 Fuller Ave NE, Grand Rapids, MI 49503 616-632-7210 www.accesskent/health/laboratory.htm
Issued Under Authority of P.A. 368, 1978
Collection and Shipping Instructions
Revised 06/2018
Samples can be sent by the company of your choice, samples should not be shipped Thursdays, Fridays or before a holiday.
Shipping address if using UPS or FEDEX is
KCHD-Laboratory
700 Fuller Ave, NE
Grand Rapids, MI 49503
Shipping address if using USPS is
KCHD-Laboratory
PO Box 355
Grand Rapids, MI 49501
A. For all testing Complete the Request for Water Analysis form (on reverse side) for each set of samples submitted.
B. Enclose fee (fees are listed on reverse) with sample, testing will not be initiated without payment.
C. Wash your hands thoroughly with soap and water. Select a clean, cold-water faucet in good working order.
D. Do not open the bottle until you are ready to collect the sample. DO NOT RINSE THE BOTTLE BEFORE COLLECTING
THE SAMPLE! Do not touch the inside of the cap or the bottle.
Bacteria
(Total Coliforms & E.Coli)
125 mL clear bottle with a white
cap, with a seal.
Please note: there is a white
powder (Sodium Thiosulfate)
chemical preservative in this bottle.
1. Remove attachments: aerators (small screen), and hose connections. Disinfect faucet with
bleach.
2. Allow the water to run at full flow for about 10 minutes (until water is cold).
3. Reduce the flow to avoid splashing, and collect the sample directly into the collection bottle.
DO NOT allow water from the outside surface of the faucet or tap to drip into the bottle.
4. Fill the bottle just above the 100 mL line, 100 mL is REQUIRED to perform the testing. Screw
the cap tight to prevent leakage, store at <10◦C and return the sample to the laboratory,
testing must be started within 30 hours from collection time. For Surface waters, testing
must be started within 6 hours from collection time.
Partial Chemistry
(Water Quality)
125 mL cloudy bottle with a black
cap, does not have a seal.
NEVER USE THE BOTTLE WITH THE
PRESERVATIVE FOR TESTING!
1. Remove attachments: aerators (small screen), and hose connections.
2. Allow the water to run at full flow for about 10 minutes (until water is cold).
3. Collect the sample directly into the collection bottle. DO NOT allow water from the outside
surface of the faucet or tap to drip into the bottle.
4. Fill the bottle to the bottom of the bottle neck. Screw the cap tight to prevent leakage.
5.
SAMPLES MUST BE STORED AT C AND SHIPPED OR DELIVERED TO THE LABORATORY IN A
COOLER WITH ICE PACKS. TESTING MUST BE COMPLETED WITHIN 48 HOURS OF
COLLECTION.
Lead
125 mL amber bottle with a white
cap
1. The sample must be the FIRST DRAW after the 6 hour waiting period. Do not collect samples
after a long weekend or when the faucet has not been used for an extended period. Water
MUST NOT BE IN USE FOR 6 HOURS PRIOR TO TESTING (Do not flush toilets, run faucets, or
run appliances).
2. Choose a faucet used for drinking i.e. kitchen or bathroom.
3. Collect the sample directly into the collection bottle. Fill the bottle just above the 100 mL line
100 mL is REQUIRED to perform the testing. Screw the cap tight to prevent leakage and return
the sample to laboratory within 14 days of collection.
Arsenic
125 mL amber bottle with a white
cap
1. Remove attachments: aerators (small screen), and hose connections.
2. Allow the water to run at full flow for about 10 minutes (until water is cold).
3. Collect the sample directly into the collection bottle. DO NOT allow water from the outside
surface of the faucet or tap to drip into the bottle.
4. Fill the bottle to the bottom of the bottle neck. Screw the cap tight to prevent leakage and
return the sample to laboratory within 14 days of collection.
Corrosion Control
(Lead & Copper)
1000 mL amber bottle with a white
cap
1. Samples for Compliance with the Lead and Copper Rule MUST be submitted in a 1000mL
collection container.
2. The sample must be the FIRST DRAW after the 6 hour waiting period. Do not collect samples
after a long weekend or when the faucet has not been used for an extended period. Water
MUST NOT BE IN USE FOR 6 HOURS PRIOR TO TESTING (Do not flush toilets, run faucets, or
run appliances).
3. Choose a faucet used for drinking i.e. kitchen or bathroom.
4. Collect the sample directly into the collection bottle. Fill the bottle just above the 1000 mL line
1000 mL is REQUIRED to perform the testing. Screw the cap tight to prevent leakage and
return the sample to laboratory within 14 days of collection.