Free 39231.pdf - Indiana


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Date: August 22, 2006
File Format: PDF
State: Indiana
Category: Government
Author: makidwell
Word Count: 666 Words, 4,148 Characters
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http://www.state.in.us/icpr/webfile/formsdiv/39231.pdf

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Public Water System Report
INDIANA STATE DEPARTMENT OF HEALTH Environmental Microbiology Laboratory 635 North Barnhill Drive, Room #13G Post Office Box 7202 Indianapolis, Indiana 46207-7202

Sample Number

Date Reported

Date Received

State Form 39231 (R8/2-06)

Samples submitted without completed form will not be analyzed. Use black ink.

ANALYSIS DATA

TEST: TOTAL COLIFORM
METHOD*: MF RESULT: MPN LST P/A ABSENT
Most Probable Number

Indiana State Department of Health is to mail report to:
Name:

MM P/A

MM QT

Street:

PRESENT IN Analyst:

City:

ZIP:

TO BE COMPLETED BY PUBLIC WATER SYSTEM

TEST:
METHOD*: MF RESULT:

TOTAL COLIFORM
MPN LST P/A MM P/A

E COLI
MM QT

PWS ID: CERTIFIED LAB ID NUMBER: Organization Phone Number: 5 2 4 9 2

PRESENT Analyst:

ABSENT
Most Probable Number

County:
HETEROTROPHIC

Date: Time: Sampling Address: Chlorine Residual at Sampling Address: Sample Collected by: mg/l Location Code:

PLATE COUNT:

/1.0ML

/0.1ML

*If MPN or MMQT is checked, the result is a statistical determination of the most probable number per 100ml. If MF is checked, the result is organisms per 100ml. If P/A is checked, the result is present or absent. REPORT OF SAMPLES
SUBMIT REPEAT SAMPLES as required under 327 IAC 8-2-8.1 PLEASE SUBMIT ANOTHER SAMPLE. TEST NOT VALID DUE TO:

SAMPLE TYPE (check appropriate square):
D ­ Distribution C ­ Repeat O ­ Other

Too long in transit (more than 30 hours) Invalid or no collection date and/or time Sample leaked or broken in shipment, insufficient volume Residual chlorine present

Date Original Sample Collected (if sample is a repeat):

Other

Remarks:

Directions for Completing State Form 39231, Public Water System Report
A. Print clearly, filling in ALL information in the left-hand column of the bacteriological report form. B. Return the completed form with your sample to the laboratory within 30 hours of collection. Samples over 48 hours old will not be analyzed. C. Fill in the following information: 1. ADDRESSES to which the examination results should be sent. 2. PWS ID ­ This is a unique number assigned your water supply for identification purposes. It is required for the analysis to be performed. 3. Phone number of the Public Water System. 4. SAMPLING ADDRESS AND LOCATION CODE ­ A system representing the sampling location is required under 327 IAC 8-2(a). Each sampling location can be assigned a unique 4-digit number (location code) by the water operator. e.g., Sampling address JOHN DOE RESIDENCE Which tap LAUNDRY ROOM SINK

Location Code 0 0 0 1

5. DATE OF SAMPLE ­ Use month, day, and year sample was taken. 6. TIME OF SAMPLE ­ Indicate the time of day the sample was taken using the 2400-hour terminology. 7. CHLORINE RESIDUAL ­ Indicate chlorine residual.

8. TYPE OF SAMPLE ­ Check appropriate square to indicate type of sample. 9. REMARKS ­ Indicate the type of sample, i.e., raw water, new main, etc. D. ALL SAMPLES MUST BE RECEIVED IN THE LABORATORY BY 3:00 PM, INDIANAPOLIS TIME. E. USE THE ENCLOSED BOTTLE. SAMPLES SUBMITTED IN OTHER CONTAINERS WILL NOT BE ANALYZED. THIS BOTTLE CONTAINS SODIUM THIOSULFATE WHICH MAY APPEAR AS DROPLETS OF A WHITE POWDER. DO NOT RINSE OUT THE BOTTLE. FILL EXACTLY TO THE 100 ML LINE.

EXPLANATION OF SAMPLE STATUS
ANOTHER SAMPLE MUST BE SUBMITTED IF ANY OF THE FOLLOWING ARE INDICATED ON THE REVERSE. 1. TOO LONG IN TRANSIT: Sample received more than 48 hours after collection. NOTE: RESULTS OF SAMPLES RECEIVED MORE THAN 30 HOURS AFTER COLLECTION MAY BE INVALID. INVALID OR NO COLLECTION DATE AND/OR TIME: Samples will not be run without a date or time, samples received in lab with date of collection later than time received has an invalid date. SAMPLE LEAKED OR BROKEN IN SHIPMENT, INSUFFICIENT VOLUME: Sample container was damaged or leaked in transit resulting in insufficient sample volume, test procedure requires 100 ml. RESIDUAL CHLORINE: The presence of chlorine in the sample interferes with testing, invalidating the sample. HIGH BACKGROUND COUNT: Sample contained a large number of bacteria, which inhibits an accurate determination of coliform bacteria.

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