Free New TCR eForm (ICPR Format) (40 - Indiana

TCR
MONTHLY TOTAL COLIFORM REPORTING
State Form 53297 (6-07)

Indiana Department of Environmental Management (IDEM) Office of Water Quality - Drinking Water Branch - Compliance Section

Lab Received: (MM/DD/YY) Time Received:

.
:

.
AM PM

CERTIFIED LAB ID NUMBER

M Lab Sample ID:

-

Date Reported:

TO BE COMPLETED BY THE PUBLIC WATER SYSTEM
Samples will not be analyzed if form is not complete. Use black ink.

ANALYSIS DATA - FOR LAB USE ONLY

Laboratory - please send a copy to: Name: _________________________________________

TEST RESULTS: TOTAL COLIFORM
METHOD:
MF MPN LST P/A MM P/A MM QT

Street:_________________________________________ City: ______________________ IN (ZIP)__________ )_____ - _________

RESULTS: PRESENT
Analyst:

MOST PROBABLE NUMBER:

Organization Phone Number:( PWSID:

ABSENT
Date: FECAL COLIFORM Time: E COLI

I N
Collection Date (MM/DD/YYYY): Collection Time:

TEST RESULTS:
METHOD: AM PM
MF MPN

.

.

:

LST P/A

MM P/A

MM QT

Sample Location Address:

RESULTS: PRESENT ABSENT
Date:

MOST PROBABLE NUMBER:

Sample Comments/Remarks (Tap, Sink, Boil Water, etc)

Analyst:

Time:

HETEROTROPHIC PLATE COUNT: Chlorine Residual at Sample Location:

.
Free Total

mg/L

/1.0 mL Too Many To Count(TMTC)

/0.1 mL

Additional Comments: __________________________________________________ __________________________________________________ __________________________________________________

*If MPN or MMQT is checked, the result is a statistical determination of the most probable number per 100 mL. If MF is checked, the result is in organisms per 100 mL. If P/A is checked, the result is present or absent.

REASON FOR REJECTING THE SAMPLE: SUBMIT REPEAT SAMPLES as required under 327 IAC 8-2-8.1 SUBMIT ANOTHER SAMPLE. The test is not valid because of:

SAMPLE TYPE (check appropriate square) Routine Repeat Special

Date Original Sample was collected (only if Repeat):

.

.

(MM.DD.YYYY)

Too long in transit (>48 Hrs); Invalid or no collection date and/or time;

Printed Name & Initials of Sample Collector:

Sample broken or leaked in transit (insufficient volume); Residual chlorine present; Other:____________________________.

Printed Name & Initials of Certified Operator: