Form 46270 - Water Test Kit Order - Indiana State Department Of Health
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1FOR ISDH USE ONLY
Date Received________________________________________
WATER TEST KIT ORDER
State Form 46270 (R2/10-99)
Receipt No.__________________________________________
Approved by State Board of Accounts 1999
Shipping No._________________________________________
Name_______________________________________________
Phone
(
)_____________________________________
Address_____________________________________________
PWS ID No.____________________________________
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
Bacteriology
Fluoride/Sodium
Total Nitrate-
Nitrite Sample
Total Kits
IDEM MONITORING
Sample Kit
Sample Kit
Nitrite
Kit
Sample Kit
Municipal Water Supply (No Fee)
Business ($8.00)
Mobile Home Park ($8.00)
School (No Fee)
Other ($8.00)
ISDH/WELFARE MONITORING
Bacteriology
Fluoride/Sodium
Total Nitrate-
Nitrite Sample
Total Kits
Sample Kit
Sample Kit
Nitrite Sample
Kit
Kit
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/
Bacteriology
Fluoride/Sodium
Total Nitrate-
Nitrite Sample
Total Kits
UNMONITORED
Sample Kit
Sample Kit
Nitrite Sample
Kit
Kit
Private Individual/Business
Realtor/Inspection Company
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
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