Read Laboratory Certification Application text version

ADEM Drinking Water Laboratory Certification Application

(PRINT OR TYPE INFORMATION)

Laboratory Name: _____________________________________________________ New Application: Renewal:

If Lab Changed Names since the Last Certification, indicate Previous Lab Name: ___________________________________________

Laboratory Contact: ____________________________________________________

Address: _____________________________________________________________

City: __________________________

State: _________ Zip: ________________

Telephone #: _______________________

Fax #: ______________________

Email Address: _____________________________________________________________

Laboratory Certification Type Applying For: In-state Parameter Groups Applying For: Microbiological: Inorganics: Metals: Asbestos: Herbicides: Pesticides: Radiologicals: Dioxin:

Out-of-state

Disinfection Byproducts: Volatile Organic Chemicals: Synthetic Organic Chemicals:

I hereby affirm the information provided in this application and attachments is true and correct. _____________________________________ Signature of Laboratory Manager/Director ________________ (Title) ___________ (Date)

LAB ID #: ______________________

ADEM Form 442 11/12 m2

(ADEM USE ONLY)

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Laboratory Certification Application

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