Environmental Shop

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Water Testing Order Form
You are purchasing a Water Testing Kit from Dakota County, Minnesota.  Please fill out the information below to complete your application order.  After completing the form, click the "Place order" button at the bottom.  You will receive a confirmation number once the order has been submitted and your credit card has been charged.
How did you hear about the water testing service (Please Select One) *
Mail/Flyer Online Search Friend/Family County Staff Well Driller or Other in Well Industry Social Media Other: *
Reason for Test (Please select one)
Routine Retest Refinancing Property Sale / Transfer Repair Daycare
Shipping Information
First Name:	*
Last Name:	*
Address	*
City	*
State	*
Zip	*
Contact Phone Number	- ** *
E-Mail Address	*
Available Kit Information
Select the items you'd like to include in your kit, each chemical is $21.00.
Coliform bacteria $21.00
Nitrate $21.00
Manganese $21.00
Arsenic $21.00
Lead $21.00
Fluoride $21.00
Select a Kit Return option.
Sample Return Shipping
Sample Drop off
Google Maps Directions to Western Service Center  Driving Directions
Total Fee
*Note:  To order another kit please return to home page.
Payment Information
Payment form	Credit Card
Credit Card Type	MasterCard Visa
Credit Card Number Enter number only no dashes. * **	CVC * ** What is a CVC Code ?
Credit Card Expiration	MM 1 2 3 4 5 6 7 8 9 10 11 12 * /   YYYY 2023 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 2034 2035 2036 2037 2038 2039 2040 2041 *
Cardholder same as Owner?
Cardholder First Name	*
Cardholder Last Name	*
Cardholder CompanyName
Address	*
City	*
State	*
Zip Code	*
Phone Number	* **

Release Version 17.09  January 04, 2023
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