"Water and Radon Test Order Form" - Vermont

Water and Radon Test Order Form is a legal document that was released by the Vermont Department of Health - a government authority operating within Vermont.

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Vermont Department of Health Laboratory – Water and Radon Test Order Form
Mailing Address: PO Box 1125, Burlington, VT 05402-1125
Physical Address: 359 South Park Drive, Colchester VT 05446 ● (802) 338-4724 / (800) 660-9997 in VT only
Orders may be submitted using one of the following options:
1.
Mail to: Vermont Department of Health Laboratory (see mailing address above)
2.
Phone: 802-338-4736 (Kit Ordering direct line) or 1-800-660-9997
3.
Fax: 802-338-4706
Shipping Information
Company Name (If applicable)
Customer/Contact Name
Shipping Address (if different than mailing address)
Mailing Address
City/Town
State
Zip Code
Telephone Number
Email
This Box is for Regulated Water Systems Only
Water System Name:
WSID #
Method of Payment: (Payment must accompany the order)
Check
Discover
Purchase Order # __________________________________
Visa
MasterCard
Credit Card
Number:
Expiration Date:
3 Digit Security Code (See back of card)
Total Coliform/E. coli (Enzyme Substrate Tests)
Quantity
Kit Name
Description
Price
Total
A
Presence/Absence (Homeowners)
$14.00
AA
Presence/Absence (Regulated Systems)
$14.00
AG
Irrigation Water
$15.00
SW
Recreational Water
$15.00
NU
Total Coliform/E. coli Count
$15.00
LT
Total E. coli Count from Source Water (Regulated Systems Only)
$15.00
Inorganic Chemistry (IOC)
Quantity
Kit Name
Description
Price
Total
C
Inorganic Chemicals (Homeowners)
$100.00
IA
Inorganic Chemicals (Regulated Systems)
$125.00
IB
Lead and Copper
$20.00
ID
Inorganic Chemicals (Some Permitted Systems)
$90.00
AN
Anions: Chloride, Fluoride, Nitrate, Nitrite, Sulfate
$50.00
N3N2
Nitrate and Nitrite
$24.00
Child Care and School Water Testing
Quantity
Kit Name
Description
Price
Total
DC Lead
Lead First Draw or Lead Flush (Public and Private Water Systems)
$12.00
DC Inorganic
Inorganic (Private Water Systems):
$74.00
Arsenic, Uranium, Nitrite, Manganese, Nitrate, Fluoride
DC Coliform
Colif orm/E. coli (Private Water Systems)
$14.00
Admin 501 Rev 11 (7/20/21)
Page 1 of 2
Vermont Department of Health Laboratory – Water and Radon Test Order Form
Mailing Address: PO Box 1125, Burlington, VT 05402-1125
Physical Address: 359 South Park Drive, Colchester VT 05446 ● (802) 338-4724 / (800) 660-9997 in VT only
Orders may be submitted using one of the following options:
1.
Mail to: Vermont Department of Health Laboratory (see mailing address above)
2.
Phone: 802-338-4736 (Kit Ordering direct line) or 1-800-660-9997
3.
Fax: 802-338-4706
Shipping Information
Company Name (If applicable)
Customer/Contact Name
Shipping Address (if different than mailing address)
Mailing Address
City/Town
State
Zip Code
Telephone Number
Email
This Box is for Regulated Water Systems Only
Water System Name:
WSID #
Method of Payment: (Payment must accompany the order)
Check
Discover
Purchase Order # __________________________________
Visa
MasterCard
Credit Card
Number:
Expiration Date:
3 Digit Security Code (See back of card)
Total Coliform/E. coli (Enzyme Substrate Tests)
Quantity
Kit Name
Description
Price
Total
A
Presence/Absence (Homeowners)
$14.00
AA
Presence/Absence (Regulated Systems)
$14.00
AG
Irrigation Water
$15.00
SW
Recreational Water
$15.00
NU
Total Coliform/E. coli Count
$15.00
LT
Total E. coli Count from Source Water (Regulated Systems Only)
$15.00
Inorganic Chemistry (IOC)
Quantity
Kit Name
Description
Price
Total
C
Inorganic Chemicals (Homeowners)
$100.00
IA
Inorganic Chemicals (Regulated Systems)
$125.00
IB
Lead and Copper
$20.00
ID
Inorganic Chemicals (Some Permitted Systems)
$90.00
AN
Anions: Chloride, Fluoride, Nitrate, Nitrite, Sulfate
$50.00
N3N2
Nitrate and Nitrite
$24.00
Child Care and School Water Testing
Quantity
Kit Name
Description
Price
Total
DC Lead
Lead First Draw or Lead Flush (Public and Private Water Systems)
$12.00
DC Inorganic
Inorganic (Private Water Systems):
$74.00
Arsenic, Uranium, Nitrite, Manganese, Nitrate, Fluoride
DC Coliform
Colif orm/E. coli (Private Water Systems)
$14.00
Admin 501 Rev 11 (7/20/21)
Page 1 of 2
Organic Chemistry (VOC and SOC)
Please indicate the month you would like to test:
Quantity
Kit Name
Description
Price
Total
OA
Volatile Organic Chemicals
$120.00
Disinfection By-Products
OB
Trihalomethanes
$120.00
OK
Haloacetic Acids
$150.00
SOC Group-Synthetic Organic Chemicals
SOC Group-Synthetic Organic Chemicals (includes OL, OE, OG, OH)
$630.00
OL
Semi-Volatile Chemicals and Pesticides
$250.00
OE
Herbicides in Water
$200.00
OG
Carbamate Pesticides
$100.00
OH
Ethylenedibromide (EDB) and Dibromochloropropane (DBCP)
$80.00
OP
Pentachlorophenol
$75.00
Radionuclides - Water
Quantity
Kit Name
Description
Price
Total
RA
Gross Alpha (Homeowners and Regulated)
$45.00
RC
Radon in Water
$25.00
RU
Uranium in Water (EPA Method 200.8)
$25.00
Radionuclides - Air
RF
Radon in Air (short: 2-7 days)
$50.00
RG
Radon in Air (medium: 1-3 months)
$25.00
RH
Radon in Air (long: 3-12 months)
$25.00
Individual Inorganic Chemical Tests
Quantity
Test
Price
Total
Quantity
Test
Price
Total
$12.00
$12.00
Alkalinity
Lead
$12.00
$12.00
Antimony
Manganese
$12.00
$25.00
Arsenic
Mercury
$12.00
$12.00
Barium
Nickel
$12.00
$12.00
Beryllium
Nitrate
Cadmium
$12.00
Nitrite
$12.00
Calcium, Titration
$12.00
Odor
$10.00
$12.00
$10.00
Chloride
pH
$12.00
$12.00
Chlorine Residual, Free
Selenium
$12.00
$12.00
Chlorine Residual, Total
Sodium
$12.00
$15.00
Chromium
Sulfate
$12.00
$12.00
Conductivity
Thallium
$12.00
$12.00
Copper
Total Dissolved Solids
Fluoride
$12.00
Turbidity
$12.00
Hardness
$12.00
Uranium (Kit RU)
$25.00
$12.00
$12.00
Iron
Zinc
NOTE: For detailed test kit descriptions, refer to the Water Test Order Form Supplement Admin 909 at http://healthvermont.gov/lab/forms.
Total Due:
______________
Records relating to water testing are public. Public records may be used for statistical purposes, and may be released upon request in writing,
pursuant to Vermont access to public document law (1 VSA § 315-320). The Vermont Department of Health Laboratory (VDHL) reserves the
right to subcontract analytical testing to other certified laboratories if the work cannot be performed at the VDHL. For more information please
refer to the VDHL website at: http://healthvermont.gov/lab.
Admin 501 Rev 11 (7/20/21)
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