Town of Carlisle, MA - Voluntary Well Testing Sign Up Form

Voluntary Well Testing Sign Up Form

VOLUNTARY WATER TESTING

May 31, 2008

Name:

Mailing Address:

City: Carlisle State: MA Zip: 01741

Home Phone: Work Phone:

Email:

LOCATION ADDRESS:

TEST(S) REQUESTED:

Last Date for Sign Up: Wednesday, May 21, 2008

Test	Fee	Test Requested	Amount Due	Notes
Complete Water Quality Scan: - including total coliform bacteria, E. coli bacteria, arsenic, calcium, copper, iron, lead, magnesium, manganese, potassium, sodium, alkalinity, ammonia, chloride, color, conductivity, fluoride, hardness, nitrates, nitrites, pH, odor, sulfate and turbidity.	$112.50
Volatile Organic Compounds (petroleum products, including MTBE)	$125.00
Radon (water)	$30.00
Gross Alpha	$75.00
Total Coliform (Barns)	$15.00
Sampling Fee	$20.00		$20.00
Total Paid:			$	Check #:

Checks should be made payable to: Nashoba Analytical, LLC

Mail checks to: Carlisle Board of Health

66 Westford Street

Carlisle, MA 01741

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Town of Carlisle 66 Westford Street, Carlisle, MA 01741

Phone: 978.369.6155 Fax: (978) 371-0594 townhall@carlisle.mec.edu