State Form 46270 - Water Test Kit Order

Download a blank fillable State Form 46270 - Water Test Kit Order in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete State Form 46270 - Water Test Kit Order with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

ADVERTISEMENT

Reset Form
FOR ISDH USE ONLY
Date Received (m/d/y)______________________________
WATER TEST KIT ORDER
State Form 46270 (R5 / 12-14)
Shipping Number _____________________________
Approved by State Board of Accounts, 2014
Payment ________________________________________
Business/Individual Name_______________________________________________________ **PWS ID______________________
Telephone (
) _______________________________
Contact_________________________________________________
Street Address (ship to) ________________________________________________________
County_______________________
City___________________________________________, IN_______________-_______________ (9 Digit ZIP)
The charge for bacteriological and/or chemical (total nitrate-nitrite and fluoride) testing of drinking water is $10.00 for
each test. The charge for the bacteriological testing of swimming pool water is $15.00. Each sample kit is one test.
PRE-PAYMENT REQUIRED. See Frequently Asked Questions on back of this form.
Are you a state owned facility?
Yes
No
Please indicate the number of test kits you need next to your facility type and under the sample kit type so that the correct
forms will be enclosed with your order. There is no charge (n/c) for Fluoride testing for municipalities and schools.
Fluoride
Bacteriology
Total Nitrate-
Fluoride
Total
COMMENTS
Labels
FACILITY TYPE
Sample Kit
Nitrite
Sample Kit
Kits
Sample Kit
Y/N
Private Individual/Business ($10.00)
Municipal Water Utilities ($10.00)
(n/c)
Business ($10.00)
Mobile Home Park ($10.00)
School ($10.00)
(n/c)
Other ($10.00)
Foster Home ($10.00)
Bottled Water/Ice Processor
($10.00*)
Food/Frozen Food Processor
($10.00*)
Realtor/Inspection Company ($10.00)
Bathing Beach/Lake Water ($10.00)
Swimming Pool/Pool Water ($15.00)
State Facility/Health Official (n/c)
State Facility-Swimming Pool/Pool
Water (n/c)
*Charge applies when submitted by the business.
**Public Water System assigned seven (7) digits.
a) _____Pre-paid sample test kits @ $10.00 each = $________
b) _____Pre-paid (Swimming Pool) sample test kits @ $15.00 each = $ ________
c) Add Shipping and Handling for entire order (mail order only) $6.50
TOTAL ENCLOSED $__________
d) _____ No charge (Fluoride) sample kits (Municipal Water Utilities and Schools no shipping /handling)
P.O. _________________ (Municipal Water Utilities Only)
Make check or money order (no cash please) payable to Indiana State Department of Health and mail or bring to:
ISDH Laboratories – Attn: Containers
th
550 W. 16
Street, Suite B
Indianapolis, IN 46202
(317) 921-5874

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Legal
Go
Page of 2