Form 36740 - Health Official/pools & Spas/beaches & Lakes Report
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HEALTH OFFICIAL/POOLS & SPAS/BEACHES & LAKES REPORT
INDIANA STATE DEPARTMENT OF HEALTH
Environmental Microbiology
Shipping Number ___________
Sample Number _____________
th
550 W. 16
Street, Suite B
Indianapolis, Indiana 46202-2203
Date Rep. ________________
Date Received _____________
ANALYSIS DATA--TO BE COMPLETED BY LAB
SAMPLES SUBMITTED WITHOUT COMPLETED FORM WILL
NOT BE ANALYZED. USE BLACK INK.
TEST: TOTAL COLIFORM
Indiana State Department of Health is to mail report to:
METHOD:*
MF
MPN
LST P/A
MM P/A
MM QT
Name:______________________________________________
RESULT:
Street:______________________________________________
PRESENT
IN
City:_____________________________
(ZIP)____________
ABSENT
ANALYST:
SAMPLE SUBMITTED BY:____________________________
TEST:
FECAL COLIFORM
E. COLI
HEALTH OFFICIAL _______________________
METHOD:*
(COUNTY)
MF
MPN
EC P/A
MM P/A
MM QT
IDENTIFICATION NUMBER
BOTTLE NUMBER
RESULT:
PRESENT
ABSENT
EMAIL_____________________________________________
ANALYST:
SAMPLE SOURCE (CHECK ONE):
*If MPN or MMQT is checked the result is the most probable
Drinking Water
Swimming Pool
Spa/Hot Tub
number per 100ml.
Bathing Beach
Surface Water-
Ice
If MF is checked the result is organisms per 100 ml.
Ditch, etc.
If P/A is checked the result is presence (P) or absence (A).
Meat/Poultry Plant
Bottled Water
Dairy
Incidental Pseudomonas Detected
HETEROTROPHIC
OTHER ________________________________________
PLATE COUNT ___________ /1.0 ML___________ /0.1 ML
NAME/ORGANIZATION ______________________________
Report of Samples
ADDRESS ________________________________________
SATISFACTORY:
At examination time, this water was
LOCATION _______________________________________
bacteriologically safe based on
USEPA standards.
PHONE _________________________________________
UNSATISFACTORY
: At examination time, this water was
bacteriologically unsafe.
DATE COLLECTED ________ TIME COLLECTED ________
PLEASE SUBMIT ANOTHER SAMPLE.
ADDITIONAL REPORTS ARE TO BE MAILED TO:
TEST NOT VALID BECAUSE:
_________________________________________________
Too long in transit (more than 30 hours).
(Name)
Invalid/no collection date.
_________________________________________________
(Street)
Incomplete information.
____________________________ IN _________________
Other ______________________________________
(City or Town)
(ZIP)
State Form 36740 (R7 / 9-07)
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