You must have JavaScript enabled to use this form. Name of the Requestor Date Requested Department Contact Number Email Sample Types Air (IAQ) Asbestos Lead Other If checked Other, Please describe here Location Building Room If Asbestos or Lead, where in room? Other Location Reason for Request (Details on repair or renovation, Water damage, etc.) Results Needed Same Day (only samples tested by EHS ONLLY) URGENT-NEXT DAY (Laboratory Premium Charges Will Apply) Within 3 days Within 7 days Within 2 weeks Mail Service Requested Standard Overnight (Premium Charges Will Apply) BMC Work Order # EHS Work Order # PS Chartfield String (to use for payment) Estimated Cost (to be filled in by EHS) $ Additional Notes Date EHS issued results to requestor EHS Representative Signature Date