HomeMy WebLinkAboutSTAR ROUTE A LT 1Onsite File
T
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FOR
phone:
06 1220~~- ;R~v.~973
DATE
ALA DEPARTMENT OF HEALTH AND SOCIAL S~ iCES
DIVISION OF PUBLIC HEALTH
INDIVIDUAL AND SEMI-PUBLIC
BACTERIOLOGICAL WATER ANALYSIS
Lab No.
OFFICE
INDIVIDUAL [~
lAME
~DDRESS
SEMI-PUBLIC [] CHLORINE RESIDUAL PPM
REPORT RESULTS~TO
CITY
ZIP CODE
ADDRESS
OF SOURCE
Analysis shows this Water SAMPLE to be:
[] Satisfactory
[] Unsatlsfaclory
[] Questionable
[] Sample fao long in transit; sample should hal be over 48
hours old al examlnatlon fo ind~cate reliable results. Please
send new saml~le.
[] Botlle broken in transit, olease send new sampJe.
SANITARIAN'S REMARKS
COMPLETE THIS SECTION
ONLY IF WATER IS AN INDIVIDUAl SUPPLY
SAMPLE COLLECTED BY
DATE COLLECTED
[] Other (List)
TIME COLLECTED
[] Kitchen TaB [] Balhroom Tap [] Basement Tap
[] Of Well [] Other
PURPOSE OF EXAMINATION: Iness Suspected? [] Yes [] N6
New Source of Supply? [] Yes [] No SepaJrs to System? [] Yes [] No Signature
READ INSTRUCTIONS
ON
REVERSE SIDE
BEFORE
COLLECTING SAMPLE
06-1220 ~g~ BACTERIOLOGICAL WATER ANALYSIS ~ECORD
mm
Lactose Broth 10cc T0cc ]0cc 10cc ' 10cc 1.0cc 1.0cc
24 Hours
48 Hours
EMB , ': AGAR
Lactose Broth, 24 hrs. ' 48 hfs Gram's slain
Coliform Density (Most probable No. per 100cc)
MF Results
iAbsent
Present