San Juan County Public Health
             
San Juan County Health Department
735 S 200 W Suite 2, Blanding, UT 84511
Phone: (435) 587-3838
Self-service Water Sample
NOTE: In order to do a self-service sample, you must come to our office to pick up the sample container, take the water sample yourself, and bring it back to us for shipping within the timeframe designated by the Environmental Health Director.
Personal Info Form
First Name: Last Name:
Address:
Address:
City: State/Province: ZIP/Postal Code:
Phone:
Email:
Date
Owner Name
Contact Phone Number
Address of sample location
City of sample location
 
DISCLOSURE: If the results of the test are not intended solely for the sample taker, we are not responsible and do not assume liability for any improperly taken samples or for samples taken at locations other than that specified. We do not guarantee anything with self-service water samples. If you have any questions please contact Ronnie Nieves at 435-587-3838.
Sample Amount:   $30.00   Quantity:   Item Subtotal:  
$30.00
Total:
$30.00
 
Payment Information:
Processing Fee Rates:
Cards:2.5% ($1.50 min)
(1.5% surcharge for foreign cards)
eCheck:$0.75
Method of Payment:
  Credit/Debit Card
  eCheck
 Update Name from Above
Name on Account:
Routing Number:
Account Number:
Institution:
Name on Card:
Account Number:
Expiration Date:
Billing Street Address:
Billing ZIP/Postal Code:
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