*Fields marked by an asterisk are required
*Your name:
Company:
*Street address:
*City:
*State:
*Zip:
*Phone:
FAX:
*Email:
Address to be sampled:
Public Water Supply ID No.
or NJPDES Permit No.
Which of our services do you desire?
Private Well Testing
Wastewater
Environmental remediation
Solid Hazardous Waste
Water
Other
Desired turnaround time:
five days
ten days
two days
Sample will be :
Taken by Agra (required for PWTA)
Taken by me and delivered in person to Agra
Taken by me and sent by courier service to Agra
Desired report format(s):
Standard
NJDEP – Drinking Water Forms
NJDEP – NJPDES Forms
Not applicable
Report delivery method:
US Mail
FAX
Email
Do you want us to notify you if a NJDEP standard is exceeded?
Yes
No
Are you interested in periodic scheduled service?
Yes
No
OPTIONAL SURVEY:
Would online data review
capability interest you?
Yes
No
What lab are you currently using?
Which of these items are important to you when choosing a testing lab?
(Check all that apply)
Quality of service
Turnaround time
Cost
Report format
Precision and accuracy
Online reporting
How did you find out about Agra Environmental & Laboratory Services?
On the Internet
By referral
Article in a publication
From a colleague
In an advertisement
Any other notes, questions, or comments?
