APPLICATION FOR WATER TESTING - Maine



ORDER FORM FOR TESTING

PLEASE SEND ME TEST KIT(S) FOR THE FOLLOWING ROUTINE WATER TESTS

[ ] Basic Safety Test $42 [ ] Established Well $127

[ ] New Well $127 [ ] Residential Sales $127

[ ] First Draw Lead $32 [ ] SINGLE METALS $30 EACH*- List below:

[ ] OTHER TEST please specify

TESTS FOR ORGANIC COMPOUND CONTAMINANTS

[ ] REGULATED VOLATILES -EPA524.2 $160

[ ] TOC $45

RADIOLOGICAL TESTS

[ ] RADON WATER $40

[ ] RADON AIR SHORT TERM $40

[ ] GROSS ALPHA $120

Please make check or money order payable to: TREASURER OF STATE.

Send to: HEALTH AND ENVIRONMENTAL TESTING LABORATORY

221 STATE ST., STATION #12, AUGUSTA, ME. 04333.

Do not send cash

For your convenience, payment may be made by VISA OR MASTERCARD.

Visa MC Card Number CVV Code Expiration Date (MMYY)

(( ((((-((((-((((-(((( ((( ((((

Signature of Card Holder_______________________________________ Amount

NAME _______________________________________

STREET_______________________________________ TOWN___________________________________

ZIP TELEPHONE ( ) -

FEE WAIVERS: Free water testing may be available if you meet both (1.) and (2.) below:

1. Food Stamp Eligible (Please provide Food Stamp ID) or demonstrate other proof of financial need or if you have already spent $150.00 on water testing at a state certified lab.

2. There is written professional justification to support the need to test this Private Water Supply.

Examples are: Doctor’s letter, Department of Environmental Protection (DEP) Recommendation, geologist.

*For the Single Metals Test a supplemental $2.00 fee will be included to the total test for the Private Well Safe Drinking Water Fund.

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Metals testing offered:

|Aluminum (Al) |Calcium (Ca) |Magnesium (M) |Selenium (Se) |Vanadium (V) |

|Antimony (Sb) |Chromium (Cr) |Manganese (Mn) |Silicon (Si) |Zinc (Zn) |

|Arsenic (As) |Cobalt (Co) |Mercury (HG) |Silver (Ag) | |

|Barium (Ba) |Copper (Cu) |Molybdenum (Mo) |Sodium (Na) | |

|Beryllium (Be) |Iron (Fe) |Nickel (Ni) |Thallium (Tl) | |

|Cadmium (Cd) |Lead (Pb) |Potassium (K) |Uranium (U) | |

| | | | | |

$

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