HomeMy WebLinkAboutLot 20
Date __
ALASK '
ARTMENT OF HEALTH AND SOCIAL S~ ~ES
DIVISION OF PUBLIC HEALTH
Lab. No.
BACTERIOLOGICAL WATER ANALYSIS
Office
PLEASE MAIL RESULTS TO:
NAME__
ADDRESS
CITY
ZIP CODE
Sample collected by
Phone No.
Date Collected
Sampling Address ......
Time
Specific place of collection
REASON FOR SAMPLE SUBMISSION:
[] Illness suspected
[] Health Regulated Establishment
[] Other
WATER SAMPLE SOURCE
[] Well Type of casing
[] Improved (Enclosed, Covered) Spring
[] Surface (Reservoir, stream, lake)
[] Holding Tank
[] Other
Analysis shows this WATER SAMPLE to be:
[] Satisfactory
[] Unsatisfactory
[] Questionable [] submit other sample
[] Sample too long in transit to indicate reliable results.
Sample should not be over 48 hours old at time of
examination.
[] Bottle broken or leaked in transit.
[] Other
SANITARIAN'S REMARKS
Sanitafian's Signature:
__READ INSTRUCTIONS
BEFORE
COLLECTING SAMPLE
06-1220 (b)
Rev. 1978
[3ACTERIOLOGICAL WATER ANALYSIS RECORD
Date Collected . Source
Date Received-- : : Time Received p,m. Lab, No,
Presumptive 10mi [ 10m~l 10mi 10mi 10mi _.~1 ._0 mi 0.1mi
24 Hours
48 Hours
Confirmatory
24 Hours
48 Hours
EMB. Broth 24 hours:__
Multiple Tube Report:
Membrane Filter: Direct Count
Verification: LTB
Final Membrane Filter Results
Reported By
.__ Broth 48 hours:
10mi Tubes Positive/Total 10mi Portions
BGB
Date
Time: a,m,