MPALabReportForm.pdf

Colorado Department of Public Health and Environment

Compliance Assurance & Data Management Unit

REPORTING FORM FOR MICROSCOPIC PARTICULATE ANALYSIS

SAMPLER: FILL OUT ONE FORM - FOR EACH INDIVIDUAL SAMPLING POINT

PWSID #: COUNTY: DATE COLLECTED: / /

SYSTEM/ESTABLISHMENT NAME:

SYSTEM MAILING ADDRESS:

Street address/PO Box CITY STATE ZIP

CONTACT PERSON: PHONE: ( )

SAMPLE COLLECTED BY: TIME COLLECTED: _ am/pm

WATER TYPE: RAW FINISHED SURFACE GROUND

SOURCE/WTP NAME: QUANTITY SAMPLED: LITERS

For Laboratory Use Only Below This Line

LABORATORY SAMPLE # ____ SAMPLE METHOD____________________

LABORATORY NAME LAB PHONE # ( )__________________

DATE RECEIVED IN LABORATORY / / DATE ANALYZED: _ / /_______

MICROORGANISMS RAW WATER (Numbers per 100 L) FINISHED WATER (Numbers per 100 L) Cryptosporidium total IFA Count Giardia total IFA Count Nondiatomaceous Algae Diatoms Plant Debris Rotifers Nematodes Pollen Ameba Ciliates Colorless Flagellates Crustaceans Other Arthropods Insects/larvae Other Giardia by Consensus Method Coccidia by Consensus Method

EVALUATION PERCENT REDUCTION LOG REDUCTION

Centrifugate Removal Microorganism Removal Turbidity, NTU

RISK LEVEL (Ground Water)

Reviewed & Approved by Title Date

MAIL RESULTS TO: CDPHE, WQCD-CADM-B2, 4300 Cherry Creek Drive South, Denver, CO 80246-1530

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For Laboratory Use Only Below This Line