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WATER TEST KIT ORDER The fee for bacteriological (Parke County Units of Government)

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WATER TEST KIT ORDER

State Form 46270 (R4 / 7-11)

Approved by State Board of Accounts, 2011

Facility/Name_______________________________________________ **PWS ID Number______________________________

Telephone ( ) _____________________________________ Contact___________________________________________

Street Address________________________________________________ County_______________________________

City___________________________________________, IN_______________-_______________ (9 Digit Zip)

The fee for bacteriological testing and chemical (total nitrate-nitrite/fluoride/sodium/nitrite) testing of drinking water for

private individuals is $10.00 for each test. The fee for the bacteriological testing of swimming pool water is $15.00.

PRE-PAYMENT REQUIRED

Are you a state 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

paid forms will be enclosed with your test kit.

There is no charge (n/c) for Fluoride testing for municipalities and schools.

Bacteriology

Sample Kit

Total Nitrate-

Nitrite

Sample Kit

Fluoride/Sodium

Sample Kit

Nitrite Sample

Kit

Total Kits

Private Individual/Business ($10.00)

Municipal Water Supply ($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 (No Fee)

State Facility-Swimming Pool/Pool

Water (No Fee)

*Charge applies when submitted by the business. **Public Water System assigned seven digits.

a) Total number pre-paid

sample test kits ______x $10.00 each = $________

b) Total number pre-paid

(Swimming Pool) sample test kits ______x $15.00 each = $ ________

c) Plus Shipping and Handling Fee for entire order (mail order only) $6.50

d) Total no charge

(fluoride/sodium) sample kits _______ (no shipping & handling fee for Municipal Water Supply)

e) P.O. _________________ (Water Utilities Only) TOTAL COST $______________

Please make check or money order (no cash please) payable to Indiana State Department of Health and mail or bring to:

ISDH Laboratories – Attn: Containers

550 W. 16

Street, Suite B

Indianapolis, IN 46202

(317) 921-5874

FOR ISDH USE ONLY

Date Received (m/d/y)______________________________

Approved Date (m/d/y) _____________________________

Payment ____________________________________________

Reset Form

FREQUENTLYASKEDQUESTIONS



Q:WhatdoIneedfortestingmywater?

A:Awatertestkit‐asamplebottleanda“PAID”submissionformwithbarcode.TheWater

TestKitOrderformcanbedownloadedathttp://www.in.gov/isdh/19042.htm.



Q:WhatcanItestmywaterfor?

A:Bacteria(coliform);Fluoride/Sodium;TotalNitrate‐Nitrite;andNitrite.



Q:HowdoIobtainawatertestkit?

A:Thewatertestkit(s)canbeshippedtoyourlocation;orpickedupatthe

ISDHLaboratories,MondaythruFridaybetween8:15amand4:30pm,exceptStateholidays.



Q:Whatisthecostforadrinkingwatertestkit?

A:Unlessyouqualifyforalistedexemption,thecostis$16.50pertest($10.00+$6.50s/h).

IfpickedupattheISDHLaboratoriesthecostis$10.00.SwimmingPoolkits$15.00.

Example:4Bacti(pool)kitsis$60.00+$6.50=$66.50.



Q:Doyouacceptcredit/debitcardsaspayment?

A:No.Pre‐paymentisrequiredwithacheckormoneyordermadeouttoISDH.



Q:DoIgetareceiptformywatertestkitpurchase?

A:No.Allpre‐paidordersarestamped“PAID”inredontheupperleftofthe

submissionform.Onlyoriginalbar‐codedformsareaccepted.NODUPLICATES.



Q:IfIpurchasedatestkitdoIstillneedtosendinacheckwiththebottle?

A:No.Onceyouhavepaidforthekitnoadditionalmoneyisdue.Checkyourformfor“PAID”.



Q:HowsoonafterorderingwillIgetmyorder?

A:Expectdeliverywithintwo(2)businessdaysafterreceiptoftheWaterTest

KitOrderformandpayment.Pleasenote

:TheISDHLaboratoriesshipskitsbyUPS.

UPSdoesnotdelivertoP.O.Boxes,onlytostreetandroadaddresses.



Q:Isentinawatersampleandwastolditwastoolongintransit.DoneedI

topayforanothertestkit?

A:Yes.Inorder

forthisnottohappenagain,pleasereadtheinstructionsonthe

submissionformasitpertainstosamplingrequirements.



Q:Ihavealreadypaid$100toIDEM.Doesthiscoveranyofthewatertesting?

A:No.ItisanadministrativefeerequiredbyIDEMfortheirpurposes.



Q:Ihavereceivedthewatersamplekit,buthavequestionsabouttesting.WhodoIcontact?

A:Call317‐921‐5874andyouwillbedirectedtothelabareathatcanansweryourquestions.

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