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Property Address *

Number of Bedrooms *

Township *

Expected Closing Date

Tax ID

OWNER/BUYER INFO

Name *

Cell/Mobile Phone

Home Phone

Owner/Buyer Address

REALTOR INFO

Name

Company

Email *

Mobile/Cell

Alt Phone Number

Fax

Mailing Address

Contact for service needs/arrangements

If other, who?

Send report via

PROPERTY INFO

Is there electric power?

Yes No

Is the property vacant?

Yes No

If yes, how long?

Services Requested - MUST PICK CASH/CHECK OR CREDIT CARD PRICE

[CASH/CHECK DISCOUNT PRICE] Septic Only (Includes: "Locate And Expose Septic System") - $275.00 Well Only - (Includes: Bacterial/Nitrate samples) - $225.00 Septic and Well (Includes: "Locate And Expose Septic System" and Bacterial/Nitrate Samples) - $325.00 Dewinterize/Rewinterize - $75.00/well Locate, Expose and Diagram Septic System - $150.00/hr., 1 hour min. Lead Water Analysis (7-10 Day Turnaround by PACE Labs) - $75.00. Arsenic Water Analysis (7-10 Day Turnaround by PACE Labs) - $75.00 Nitrites (if requested, there is an additional 20.00 lab fee, check with underwriter/loan officer) - $20.00 [CREDIT CARD PRICE INCLUDES ALL FEES (Processing fee)] Septic Only (Includes: "Locate And Expose Septic System") - $284.00 Well Only - (Includes: Bacterial/Nitrate samples) - $234.00 Septic and Well (Includes: "Locate And Expose Septic System" and Bacterial/Nitrate Samples) - $334.00 Dewinterize/Rewinterize - $75.00/well Locate, Expose and Diagram Septic System - $150.00/hr., 1 hour min. Lead Water Analysis (7-10 Day Turnaround by PACE Labs) - $75.00. Arsenic Water Analysis (7-10 Day Turnaround by PACE Labs) - $75.00 Nitrites (if requested, there is an additional 20.00 lab fee, check with underwriter/loan officer) - $20.00 [NEW SERVICES as of JAN 2022 (CASH/CHECK DISCOUNTED PRICE)] Septic RX - General check of septic system for homeowners - should do annually - $200.00 Well RX - General check of well system for homeowners - should do annually - $200.00 w samples $250.00 Sewer Line Scope - check line from house to private septic or public sewer - $200.00 Sample Well or City Water - includes bacteria/nitrate sample - $100.00 [NEW SERVICES as of JAN 2022 (CREDIT CARD PRICE INCLUDES ALL FEES) (Processing fees)] Septic RX - General check of septic system for homeowners - should do annually - $209.00 Well RX - General check of well system for homeowners - should do annually - $209.00 w samples $259.00 Sewer Line Scope - check line from house to private septic or public sewer - $209.00 Sample Well or City Water - includes bacteria/nitrate sample - $109.00

Payment ADD ALL CHARGES BEFORE PROCESSING CREDIT CARD or TOTAL FOR CHECK/CASH *

Has the home been winterized?

Yes No

House dewinterized and ready to sample?

Yes No

Keybox/Combination Code

Travel Fee (Outside 20 Mile Radius) *

Date of Submission

Additional Information