Bottle Order Form(Version 1.3)

Minnesota Department of Health
Public Health Laboratory Division
Environmental Laboratory Section
   Bottle Order Retrieve Form Today's Date:
*First Name:    *Last Name:

All Fields with *Pickup are required when Pickup is checked or
All Fields with *Delivery are required when Delivery is checked

*Delivery Method: Pickup    Delivery  *Delivery Date:
 *Pickup Date:
Pickup Time:
*Delivery Addr1:
Delivery Addr2:
*Delivery City: *State: *ZipCode:
*Email Address:

Please refer to the environmental lab handbook for the appropriate sample container and other lab requirements. If you have
any questions please contact or 651-201-5300.
Please allow 5 business days for processing. For RUSH orders please complete and submit form and call 651-201-5300.

Inorganic Containers Organic Containers
Qty   Qty  
 150 mL-Bacti Sterile PP  40 mL vial Set-(3)VOC Drinking Water, Chlorinated PP**
  Trip Blank Set-(3)Drinking Water, Chlorinated
 250 ml-Nutrient **
 40 mL vial Set-(3)VOC Drinking Water, Non-Chlorinated PP
  Trip Blank Set-(3)Drinking Water, Non-Chlorinated
 125 mL-Nitrate PP
 40 mL vial Set-(3)VOC Non-potable Water (also GRO) PP
  Trip Blank Set-(3)Non-potable Water
 125 mL General-Unpreserved
 40 mL vial set-(4)EDB PP
  Trip Blank Set-(2)EDB(2 required for each Sampling)
 250 mL General-Unpreserved
 SOC Kit Set(BNA,Herb,Carb,Glyp) PP**
 1 L General-Unpreserved  40 mL vial-Carbamates PP
 500 mL-Free Cyanide **
 40 mL amber vial-Glyphosate PP
 1 L Amber-Chlorophyll-a  250 mL amber-Haloacetic Acids PP
 250 mL-Total Metals(Preserved) **  250 mL amber-Herbicides PP
 120 mL-Mercury **
 1 L amber-BNA Drinking Water PP**
 4 L-Radiation Container  1 L amber-Unpreserved-PCB/SVOC/PAH TRP
  250 mL LL-Mercury **
 1 L amber-DRO TRP**
  250 mL Metals(Diss./lab-filtered)  250 mL clear-Unpreserved Flashpoint
   250 mL plastic-PFC
   60 mL Soil Jar Unpreserved and a % Moisture Jar-DRO
   250 mL Soil Jar amber-Unpreserved
  * - Required Field                                  Comments:
**- Preservative vial/dropper included
PP - Pre-Preserved
TRP-Collect one site in triplicate(per collection day or group)