Client Site Information Contact Name (First & Last) * Required Email Address * Required A copy of this completed form will be sent to the e-mail address entered here. Contact Phone Number Sample Site Confirmation of First Sampling Date * Required State PWS ID. Facility ID Facility Name Sample Collection Point ID The State of PA requires a 3-Digit number! Sample Collection Point Name Is Environmental Associates Ltd. analyzing your LT2 E. coli samples? * Required Yes No Site Address Site Address Site Address Site Address City City State/Province State/Province Zip/Postal Zip/Postal Country United States AfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCôte d'IvoireCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCroatiaCubaCuracaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSaint BarthelemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Sample #1 Method 1623Method 1623.1Ground Water Microscopic particulate analysis (MPA) for GWUDIMicroscopic particulate analysis (MPA) for Filtration EvaluationEnteric Virus Analysis for Drinking WaterTotal Culturable Virus & Helminth Ova/BiosolidsE.coliOtherNone Sample #1 Select from Drop Down Menu Sample #2 Method 1623Method 1623.1Ground Water Microscopic particulate analysis (MPA) for GWUDIMicroscopic particulate analysis (MPA) for Filtration EvaluationEnteric Virus Analysis for Drinking WaterTotal Culturable Virus & Helminth Ova/BiosolidsE.coliOtherNone Sample #2 Sample #3 Method 1623Method 1623.1Ground Water Microscopic particulate analysis (MPA) for GWUDIMicroscopic particulate analysis (MPA) for Filtration EvaluationEnteric Virus Analysis for Drinking WaterTotal Culturable Virus & Helminth Ova/BiosolidsE.coliOtherNone Sample #3 Is sample point Chlorinated? Yes No Average PH for Sample Point Sample Source Raw Water (RW) Drinking Water (DW) Surface Water (SW) Reservoir/lake (RL) Flowing stream (FS) Ground Water (GW) GWUDI (b) - FS GWUDI (b) - RL Non-Potable (NP) Waste Water - Influent (WWI) Waste Water - Effluent (WWE) Waste Water Effluent to Reclaimed Biosolids OtherOther Mark All that Apply plus1 Add Another Site Location minus1 Remove this Site Comments Document Upload Drop a file here or click to upload Choose File Maximum file size: 52.43MB Signature * Required signature keyboard Clear Date If you are human, leave this field blank.