Free 36740.pdf - Indiana

Reset Form
Shipping Number ___________

HEALTH OFFICIAL/POOLS & SPAS/BEACHES & LAKES REPORT
INDIANA STATE DEPARTMENT OF HEALTH Environmental Microbiology 550 W. 16th Street, Suite B Indianapolis, Indiana 46202-2203 Sample Number _____________

Date Rep. ________________ SAMPLES SUBMITTED WITHOUT COMPLETED FORM WILL NOT BE ANALYZED. USE BLACK INK. Indiana State Department of Health is to mail report to:

Date Received _____________ ANALYSIS DATA--TO BE COMPLETED BY LAB TEST: TOTAL COLIFORM METHOD:* MF

MPN

LST P/A

MM P/A

MM QT

Name:______________________________________________ RESULT: Street:______________________________________________

PRESENT
City:_____________________________IN (ZIP)____________

ABSENT
ANALYST: TEST: METHOD:* MF RESULT: FECAL COLIFORM E. COLI

SAMPLE SUBMITTED BY:____________________________ HEALTH OFFICIAL _______________________ (COUNTY) IDENTIFICATION NUMBER BOTTLE NUMBER

MPN

EC P/A

MM P/A

MM QT

PRESENT
EMAIL_____________________________________________ SAMPLE SOURCE (CHECK ONE):
Drinking Water Bathing Beach Swimming Pool Surface WaterDitch, etc. Bottled Water Spa/Hot Tub Ice

ABSENT
ANALYST: *If MPN or MMQT is checked the result is the most probable number per 100ml. If MF is checked the result is organisms per 100 ml. If P/A is checked the result is presence (P) or absence (A). Incidental Pseudomonas Detected HETEROTROPHIC PLATE COUNT ___________ /1.0 ML___________ /0.1 ML

Meat/Poultry Plant

Dairy

OTHER ________________________________________ NAME/ORGANIZATION ______________________________ ADDRESS ________________________________________ LOCATION _______________________________________ PHONE _________________________________________ DATE COLLECTED ________ TIME COLLECTED ________ ADDITIONAL REPORTS ARE TO BE MAILED TO: _________________________________________________
(Name)

Report of Samples
At examination time, this water was bacteriologically safe based on USEPA standards. UNSATISFACTORY: At examination time, this water was bacteriologically unsafe.

SATISFACTORY:

PLEASE SUBMIT ANOTHER SAMPLE. TEST NOT VALID BECAUSE:
Too long in transit (more than 30 hours). Invalid/no collection date. Incomplete information. Other ______________________________________

_________________________________________________
(Street)

____________________________ IN _________________
(City or Town) State Form 36740 (R7 / 9-07) (ZIP)