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RMB Environmental Laboratories, Inc.
22796 County Highway 6  Detroit Lakes, MN 56501-7002  218- 846-1465 Phone and Fax  [email protected]
DRINKING WATER FIELD SERVICE REQUEST FORM
Date of Request: ____________________________
Rush Service: 
Request Results by: __________________________
(There are additional costs for rush services. Information is included under analytical cost.)
Property Owner:_______________________________________________________________________________
Address: _____________________________________________________________________________________
Resident at Time of Order: ____________________
Is there a lock box available? __________________
Phone number at which resident may be reached to set up appointment: ___________________________________
Individual Ordering Water Test: __________________________________________________________________
Organization & Address: ________________________________________________________________________
Phone Number: _______________________________________________________________________________
Report To:
Bill To:
Business: __________________________________
Business: __________________________________
Attn To: ___________________________________
Attn To: ___________________________________
Address: ___________________________________
Address: ___________________________________
__________________________________________
__________________________________________
Fax: ______________________________________
Fax: ______________________________________
Email:_____________________________________
Email:_____________________________________
Phone Number: _____________________________
Phone Number: _____________________________
Report Preference:
Mail 
Fax 
Email 
Directions to property (Please explain in detail or fax a copy of the multiple listing sheet):
____________________________________________________________________________________________
____________________________________________________________________________________________
Analytical Requests:
 Total Coliform Bacteria $15.00
 Nitrate Nitrogen $15.00
 Arsenic $25.00
 Lead $25.00
 Hardness $27.00
Field Service Fees:
Rush Field Service:
Rush Analytical Costs:
 Bacteria Series $20.00
(Total Coliform Bacteria & E. coli Bacteria
 Nitrogen Series $20.00
(Nitrate Nitrogen. Nitrite Nitrogen, Nitrate + Nitrite Nitrogen)
 Iron $20.00  Other:_____________________
Rates begin at $64.50 and increase based upon distance from lab.
An additional $20.00 rush fee will be applied for requested same day service.
The rates for analysis will be DOUBLE for rush analytical service.
Please remit form to RMB Environmental Laboratories by one of the following:
Mail:
22796 County Hwy 6
Fax:
218-846-1465
Detroit Lakes, MN 56501
Email: [email protected]
RMB Environmental Laboratories, Inc.
22796 County Highway 6  Detroit Lakes, MN 56501-7002  218- 846-1465 Phone and Fax  [email protected]
Drinking Water Field Sampling Fees*
*effective November 15, 2011
These charges are for the collection of a drinking water sample by RMBEL field staff. Fee includes
mileage surcharge at $0.555/mile plus a technician’s drive time and average on-site sampling procedures
of 20 minutes at $45/hour.
Mileage (round trip)
Fee
0-30
$64.50
31-40
$78.50
41-50
$92.50
51-60
$106.50
61-70
$120.50
71-80
$134.50
81-90
$148.50
91-100
$162.50
101-110
$176.50
111-120
$190.50
121-130
$204.50
131-140
$218.50
141-150
$232.50
151-160
$246.50
161-170
$260.50
171-180
$274.50
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