State Form 39231 - Public Water System Report
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1PUBLIC WATER SYSTEM REPORT
INDIANA STATE DEPARTMENT OF HEALTH
Environmental Microbiology Laboratory
Sample Number ____________________
._____________________
Shipping No
635 North Barnhill Drive Rm# 13G
P.O. Box 7202
Indianapolis, Indiana 46207-7202
Date Received ____________________
____________________
Date Reported
Samples submitted without completed form will not be
ANALYSIS DATA
analysed. Use black ink.
TEST: TOTAL COLIFORM
Indiana State Department of Health is to mail report to:
METHOD*:
Name:__________________________________________________________________________
MF
MPN
LST P/A
MM P/A
MM QT
Street:__________________________________________________________________________
RESULT:
IN
City:_____________________________________________
(Zip) ____________________
PRESENT
ABSENT
TO BE COMPLETED BY PUBLIC WATER SYSTEM
ANALYST:
TEST:
FECAL COLIFORM
E coli
PWS ID
METHOD*:
CERTIFIED LAB ID NUMBER
5 2 4 9 2
MF
MPN
EC P/A
MM P/A
MM QT
Organization Phone Number __________________________
RESULT:
County ___________________________________________
PRESENT
ABSENT
ANALYST:
Date
HETEROTROPHIC
Time
Location Code
_______________/1.0 ML_______________/0.1 ML
PLATE COUNT
*If MPN or MM QT is checked the result is a statistical determination
of the most probable number per 100 ml.
If MF is checked, the result is organisms per 100 ml.
Sampling Address _________________________________
If P/A is checked, the result is present (P) or absent (A).
REPORT OF SAMPLES
Chlorine Residual at Sampling Address _______________ mg/l
Sample Collected By _______________________________
SUBMIT REPEAT SAMPLES as required under
327 IAC 8-2-8.1
SAMPLE TYPE (check appropriate square)
PLEASE SUBMIT ANOTHER SAMPLE.
D--Distribution
C--Repeat
O--Other
TEST NOT VALID BECAUSE
:
Date Original Sample Collected
Too long in transit (more than 48 hours).
(If sample is a repeat)
Invalid or n
o collection date and/or time.
Sample leaked or broken in shipment, insufficent vol.
REMARKS: __________________________________________
Residual chlorine present.
____________________________________________________
High background count.
Other___________________________________________
____________________________________________________
SDH 44-003
State Form 39231 (R6 / 5/99)
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