State Form 39231 - Public Water System Report - Indiana State Department Of Health
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2Shipping Number
Sample Number
Public Water System Report
INDIANA STATE DEPARTMENT OF HEALTH
Date Reported
Date Received
Environmental Microbiology Laboratory
th
550 W. 16
Street, Suite B
State Form 39231 (R9 / 9-07)
Indianapolis, Indiana 46202-2203
Reset Form
Samples submitted without completed form will not be analyzed.
ANALYSIS DATA
TEST: TOTAL COLIFORM
Use black ink.
Indiana State Department of Health is to mail report to:
METHOD*:
MF
MPN
LST P/A
MM P/A
MM QT
Name:
RESULT:
PRESENT
ABSENT
Street:
Most Probable Number
IN
Analyst:
City:
ZIP:
TEST:
FECAL COLIFORM
E COLI
TO BE COMPLETED BY PUBLIC WATER SYSTEM
METHOD*:
MF
MPN
LST P/A
MM P/A
MM QT
PWS ID:
RESULT:
CERTIFIED LAB ID NUMBER:
5 2 4 9 2
PRESENT
ABSENT
Most Probable Number
Organization Phone Number:
Analyst:
County:
HETEROTROPHIC
Date:
PLATE COUNT:
/1.0ML
/0.1ML
Time:
Location Code:
*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.
Sampling Address:
If P/A is checked, the result is present or absent.
REPORT OF SAMPLES
Chlorine Residual at Sampling Address:
mg/l
SUBMIT REPEAT SAMPLES as required under 327 IAC 8-2-8.1
Sample Collected by:
PLEASE SUBMIT ANOTHER SAMPLE. TEST NOT VALID DUE TO:
SAMPLE TYPE (check appropriate square):
Too long in transit (more than 30 hours)
Invalid or no collection date and/or time
D – Distribution
C – Repeat
O – Other
Sample leaked or broken in shipment, insufficient volume
Residual chlorine present
Date Original Sample Collected (if sample is a repeat):
Other
Remarks:
Printed Name and Initials of Certified Operator
__________________________________________
Fax Number________________________
Email____________________________________________
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