ࡱ> `c_o #bjbj@@ EX"dJj"dJjg@ @ kkk8cle,(   5$"W$ c$, , , , , , ,S/ 2 ,kk$#^5$k$k$ ,   ,a&a&a&k$|l k ,a&k$,a&a&:L)4?,) OEir$^) +5,0e,).2E%2)2k)<k$k$a&k$k$k$k$k$ , ,%k$k$k$e,k$k$k$k$2k$k$k$k$k$k$k$k$k$@ Y : ORDER FORM FOR TESTING ROUTINE WATER TESTS: ( Basic Safety Test (TSA) $42.00 ( Established Well (tsba) $127.00 ( First Draw Lead (pb1) $32.00 ( Residential Sales (tsfha) $127.00 ( New Well test $127 ( TG BACTERIA (POS/NEG) -- $27.00 ( TGS BACTERIA (COUNT) -- $37.00 ( RES 1 COMPREHENSIVE KIT-- $147.00 (No 1st DRAW LEAD) ( RES 2 COMPREHENSIVE KIT-- $147.00 (WITH 1ST DRAW LEAD) ( SINGLE METALS $32 EACH (see list below): _________________________________________  SHAPE \* MERGEFORMAT  TESTS FOR ORGANIC COMPOUND CONTAMINANTS: ( VOLATILE ORGANIC COMPOUNDS (VOC) $162.00 ( TOTAL ORGANIC CARBON (TOC) $52.00 RADIOLOGICAL TESTS: ( RADON WATER $42.00 ( RADON AIR (short term) $40.00 ( GROSS ALPHA $122.00 Please make CHECK or MONEY ORDER payable to: TREASURER OF STATE Send to: HEALTH AND ENVIRONMENTAL TESTING LABORATORY 47 INDEPENDENCE DRIVE, STATION #12 AUGUSTA, ME 04333 For your convenience, payment may also be made by VISA or MASTERCARD: Visa MC Card Number CVV Code Expiration (MMYY) ( ( ((((-((((-((((-(((( ((( (((( Signature of Card Holder _______________________________________ Amount NAME (or BUSINESS NAME) _______________________________________ STREET ____________________________________________ TOWN __________________ ZIP PHONE ( ) -  EMAIL ___________________________________________________ Send my results via: EMAIL ( or HARD COPY ( (choose one)  SHAPE \* MERGEFORMAT      PAGE 8 METALS TESTING OFFERED: Aluminum (Al)Calcium (Ca)Magnesium (Mg)Selenium (Se)Uranium (U)Antimony (Sb)Chromium (Cr)Manganese (Mn)Silicon (Si)Vanadium (V)Arsenic (As)Cobalt (Co)Mercury (Hg)Silver (Ag)Zinc (Zn)Barium (Ba)Copper (Cu)Molybdenum (Mo)Sodium (Na)Total HardnessBeryllium (Be)Iron (Fe)Nickel (Ni)Strontium (Sr)Cadmium (Cd)Lead (Pb)Potassium (K)Thallium (Tl) Cadmium (Cd) $ FEE WAIVERS Contact us at (207) 287-1717 to request free water testing if you meet any of the criteria below: FINANCIAL NEED: Food Stamp or fb88Care recipient (will need to provide ID#) or demonstrate other proof of financial need HEALTH CONCERN: You have written professional justification to support the need to test this Private Water Supply (Examples: Doctors letter, Department of Environmental Protection (DEP) Recommendation, geologist)  +,-.OPQbhjҠ|kYG5#hJh7-q;CJOJQJ^JaJ#hJh;NM;CJOJQJ^JaJ#hJhV;CJOJQJ^JaJ hJhwCJOJQJ^JaJ) jhJh`xCJOJQJ\^JaJhJCJOJQJ\^JaJh h{5CJOJQJ^Jh h yz5CJOJQJ^J"hp!hS75>*CJOJQJ^Jh h;CJOJQJ^JaJh-q;CJOJQJ^JaJ hJh-qCJOJQJ^JaJ) jhJh-qCJOJQJ\^JaJ" 2 3 4 ^ _ ` w x y z { | } ͼoZJJ6&hp!h*CJOJQJ^JaJh h{r5CJOJQJ^J(jh hJ5CJOJQJU^J,jh h* oOJQJU^JmHnHuh h* o5CJOJQJ^J(jh h* o5CJOJQJU^J hJh=2CJOJQJ^JaJ hJh %CJOJQJ^JaJ hJh\+?CJOJQJ^JaJ hJh;NMCJOJQJ^JaJ hJhuQQCJOJQJ^JaJ ɷo^oM<.ɢhp!CJOJQJ^JaJ hJhqjCJOJQJ^JaJ hJh}%{CJOJQJ^JaJ hJh7-qCJOJQJ^JaJ hJhwCJOJQJ^JaJ hJh _CJOJQJ^JaJ hJh`xCJOJQJ^JaJ) jhJh`xCJOJQJ\^JaJ#hJhCJOJQJ\^JaJ hJh*CJOJQJ^JaJ  H ` R S {$a$ $da$gdB!dgdS3$jd^j`a$gd yz$@ d^@ `a$gd yz $da$gd yz $da$gd yz$dh&d P a$gdp!dh^`gdp! $dha$gd7-q     ޼޼xfT?) jhJh`xCJOJQJ\^JaJ#hJh*CJOJQJ^JaJhp!CJOJQJ^JaJ hJh ACJOJQJ^JaJ hJh7-qCJOJQJ^JaJ hJhVCJOJQJ^JaJ hJhqGCJOJQJ^JaJ hJh _CJOJQJ^JaJ hJh`xCJOJQJ^JaJ    ! 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Segoe UIC. Aptos Display3. Aptos?= .Cx Courier New;WingdingsA$BCambria Math"1hggѺч  !h20 CQ@P  ?02! xxsQ APPLICATION FOR WATER TESTINGRebecca St. PierreLyons, Rachel M  Oh+'0 , L X d p| APPLICATION FOR WATER TESTINGRebecca St. Pierre Normal.dotmLyons, Rachel M2Microsoft Office Word@F#@;m@f9ir@f9ir ՜.+,0 hp  State of fb88 - DHS  APPLICATION FOR WATER TESTING Title  !"#$%&'()*+,./012346789:;<=>?@ABCDEFGHIJKLMNPQRSTUVXYZ[\]^abeRoot Entry FOEird@Data -1Table52WordDocument EXSummaryInformation(ODocumentSummaryInformation8WMsoDataStorep)OEirOEir3JXB2QNUWVLET==2p)OEirOEirItem  2PropertiesUCompObj r   F Microsoft Word 97-2003 Document MSWordDocWord.Document.89q