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WATER SAMPLE COLLECTION APPLICATION Goldendale Office Klickitat County Health Department White Salmon Office 115 West Main Street 501 NE Washington St/ PO Box 159 Box 103 White Salmon, WA 98672 Goldendale, WA 98620 [PHONE REDACTED] [PHONE REDACTED] The water sample collection results are a snapshot of the water supply at the time of collection. The Health Department does not imply or warrant any future conditions of the water system these samples were collected from. The fee for collection service is $150. This includes testing fees. APPLICANT/CONTACT INFORMATION Name: Mailing Address: City: State: Zip: Phone: Email: SITE INFORMATION Parcel Number: Site Address: City: Directions to the property: System Source: ☐Well ☐Spring ☐Other: Locked Entry? ☐Yes ☐No Key Location/Code: HEALTH DEPARTMENT USE ONLY Date of Collection: Collected for: ☐Investigative Sample Collected by: ☐Real Estate Sale Sample Location: ☐Lender/Loan ☐Building Permit Bacterial Analysis Lab#: ☐Unsatisfactory ☐Satisfactory Coli Present Coli Absent Nitrate Analysis Lab#: Mg/l: