Compliance Order Form
Job Address
Lock Box #
Need Appointment?
Yes
No
Vacant Home?
Yes
No
County
Home Built
Septic Built
Number of Bed
PID #
LUG Contact
LUG Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
LUG Email
example@example.com
Customer Type
Seller
Buyer
Realtor
Other
BILL TO Name
Billing Address
Address
Street Address Line 2
City State Zip
State / Province
Postal / Zip Code
Billing Phone
Format: (000) 000-0000.
Billing Email
example@example.com
Contact Name
Contact Phone
Format: (000) 000-0000.
Contact Email
example@example.com
Realtor
Realtor Phone
Format: (000) 000-0000.
Realtor Email
example@example.com
Ok to send results to Realtor?
Yes
No
Referred By
Have you had or Are you currently having any issues with your septic system?
Additional Notes SCI Should know?
Do you require additional services? Water Testing (Select All that apply)
Coliform/Nitrate Test
Nitrite Test
Lead Test
Arsenic Test
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