Environmental Microbiology Fresh Surface Water Examination
Katherine A. Kelley State Public Health Laboratory
395 West Street, Rocky Hill, CT 06067
Phone Number: 860-920-6699
Date/Time/Initials Received
PLEASE PRINT CLEARLY
____________________________
_
Place Lab Submitter Address and Account Information
Collected by:
Here:
Town:
Date collected:
Contact Information:
Telephone:
(please use 10-digit number)
Sample Type (Circle One):
Initial
/
Resample
Test Requested:
Fresh Surface Water
Test Number:
EC-SW
Colilert / E.coli
Time: ________________________________________
For Lab Use Only:
For Lab Use Only:
Collector’s No.: _________________________________
Lab #:
E. coli Count/100ML: ______________
Beach or Property Name: _________________________
Test:
Positive Wells: ___________________
Address: ______________________________________
Initials: _______________
Additional Info: _________________________________
Time: ________________________________________
For Lab Use Only:
For Lab Use Only:
Collector’s No.: _________________________________
Lab #:
E. coli Count/100ML: ______________
Beach or Property Name: _________________________
Test:
Positive Wells: ___________________
Address: ______________________________________
Initials: _______________
Additional Info: _________________________________
Time: ________________________________________
For Lab Use Only:
For Lab Use Only:
Collector’s No.: _________________________________
Lab #:
E. coli Count/100ML: ______________
Beach or Property Name: _________________________
Test:
Positive Wells: ___________________
Address: ______________________________________
Initials: _______________
Additional Info: _________________________________
Time: ________________________________________
For Lab Use Only:
For Lab Use Only:
Collector’s No.: _________________________________
Lab #:
E. coli Count/100ML: ______________
Beach or Property Name: _________________________
Test:
Positive Wells: ___________________
Address: ______________________________________
Initials: _______________
Additional Info: _________________________________
Time: ________________________________________
For Lab Use Only:
For Lab Use Only:
Collector’s No.: _________________________________
Lab #:
E. coli Count/100ML: ______________
Beach or Property Name: _________________________
Test:
Positive Wells: ___________________
Address: ______________________________________
Initials: _______________
Additional Info: _________________________________
For Lab Use Only:
Date and Time Analyzed: ____________________________
Analyzed by: ____________________
Rev.01/03/2013
Method (Circle test performed):
COLILERT-18
/
COLILERT-24