Free 46270 - Indiana

FOR ISDH USE ONLY

WATER TEST KIT ORDER
State Form 46270 (R2/10-99) Approved by State Board of Accounts 1999

Date Received________________________________________ Receipt No.__________________________________________ Shipping No._________________________________________

Name_______________________________________________ Phone ( )_____________________________________ PWS ID No.____________________________________

Address_____________________________________________

City___________________________________________, IN_______________-_______________ (9 Digit Zip)

The fees for bacteriological testing and chemical testing of drinking water (sodium/fluoride/nitrate/total nitrate-nitrite) for private organizations is $8.00 per sample. Please DO NOT enclose a sample with this form. Are you a state, city or county owned facility? Yes No

Please indicate the number of test kits you need next to your facility type and under your sample type so that the correct forms will be enclosed with your test kit.
DRINKING WATER IDEM MONITORING Municipal Water Supply (No Fee) Business ($8.00) Mobile Home Park ($8.00) School (No Fee) Other ($8.00) Bacteriology Sample Kit Fluoride/Sodium Sample Kit Total NitrateNitrite Sample Kit Nitrite Sample Kit Total Kits

ISDH/WELFARE MONITORING

Bacteriology Sample Kit

Fluoride/Sodium Sample Kit

Total NitrateNitrite Sample Kit

Nitrite Sample Kit

Total Kits

Foster Home ($8.00) Dairy ($8.00*) Bottled Water/Ice Processor ($8.00*) Food/Frozen Food Processor ($8.00*) Swimming Pool-Pool Water (No Fee) Bathing Beach-Lake Water (No Fee) State Facility/Health Official (No Fee)

*Charge applies when submitted by the business.
UNREGULATED/ UNMONITORED Private Individual/Business Realtor/Inspection Company Bacteriology Sample Kit Fluoride/Sodium Sample Kit Total NitrateNitrite Sample Kit Nitrite Sample Kit Total Kits

Total paid sample test kits required_____________X $8.00 per kit = $_______________enclosed. Total non-paid sample kits requested______________ Please make check or money orders (no cash or purchase orders please) payable to Indiana State Department of Health and mail to: Indiana State Department of Health Attention: Cashiers Office 2 North Meridian St. Indianapolis, IN 46204