PFAS Water Provider Settlement

Name*

First NameLast Name

Company*

Company Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Please enter a valid phone number.

Email*

example@example.com

Name for Data Report (if different than above)

First NameLast Name

Email for Data Report (if different than above)

example@example.com

Bottle Kit Shipping Name*

First NameLast Name

Email for Bottle Kit Shipping Recipient*

example@example.com

Utility Name*

Bottle Kit Shipping Address - No PO Boxes (if different from above)

Street Address - No PO Boxes

Street Address Line 2

CityState

Zip Code

Eurofins Environment Testing will only be accepting electronic payment in advance, in support of the PFAS Water Provider Settlement. A Eurofins Project Manager will contact you, after receiving this form, to confirm your sample delivery date has been accepted and to provide you with a link to process a secure payment via credit card or ACH. Refunds or adjustments to payment after the fact are NOT POSSIBLE, so please make sure to order exactly what you have confirmed you can sample and intend to submit.

Desired Bottle Kit Delivery Date*

Bottle kit includes: (2) 250mL HDPE unpreserved bottles per sample, a cooler, instructions and a Priority shipping return label.

Requested Sample Delivery Date to Lab*

Tuesday-Friday only. Sample acceptance on this date is subject to pre-approval by the laboratory. Samples must be submitted within 5 days of the approved date.

Number of Tests Needed*

Cost of each test is $540. Refunds or adjustments to payment after the fact are NOT POSSIBLE, so please make sure to order exactly what you have confirmed you can sample and intend to submit.

Additional Comments:

*Please note our business hours are 8am - 8pm ET, Monday - Friday. If it is after business hours, we will contact you the next business day. Eurofins Environment Testing does not accept samples on Sundays or Federal Holidays, such as July 4th.