ࡱ > Z ] Y 9 bjbj ;F hh; f f 8 & \ | 2 ( ( ( X2 Z2 Z2 Z2 Z2 Z2 Z2 $ 5 8 ~2 ( ( @ ( ( ( ~2 f f } 2 - - - ( R f R X2 - ( X2 - - : |0 4 " 0 !Yf #) 0 D2 2 0 2 0 . I9 ) I9 0 I9 0 \ ( ( - ( ( ( ( ( ~2 ~2 + ( ( ( 2 ( ( ( ( I9 ( ( ( ( ( ( ( ( ( X , : 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 $32 EACH*- List below: [ ] OTHER TEST please specify TESTS FOR ORGANIC COMPOUND CONTAMINANTS [ ] REGULATED VOLATILES -EPA524.2 $162 [ ] TOC $52 RADIOLOGICAL TESTS [ ] RADON WATER $42 [ ] GROSS ALPHA $122 [ ] RADON AIR SHORT TERM $40 Please make check or money order payable to: TREASURER OF STATE. Send to: HEALTH AND ENVIRONMENTAL TESTING LABORATORY221 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: 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. There is written professional justification to support the need to test this Private Water Supply. Examples are: Doctors letter, Department of Environmental Protection (DEP) Recommendation, geologist. *For the Single Metals Test a supplemental $2.00 fee is included for the Private Well Safe Drinking Water Fund. Please remove the additional fee for all but the first tested metal. PAGE 8 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) $ D Y Z [ ] ^ ` q r s t u v w z { ɿɱɝɿ{ɝɧm_ h h