State Form 39231 - Public Water System Report - Indiana State Department Of Health Page 2
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1
2Directions 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 30 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 30 hours after collection. NOTE: RESULTS OF SAMPLES
RECEIVED MORE THAN 30 HOURS AFTER COLLECTION MAY BE INVALID.
2.
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.
3.
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.
4.
RESIDUAL CHLORINE: The presence of chlorine in the sample interferes with testing, invalidating the sample.
5.
HIGH BACKGROUND COUNT: Sample contained a large number of bacteria, which inhibits an accurate determination of
coliform bacteria.
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