Form Lab-N-807 "Request for Psp Testing - Environmental Management" - California

What Is Form Lab-N-807?

This is a legal form that was released by the California Department of Public Health - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on June 28, 2013;
  • The latest edition provided by the California Department of Public Health;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form Lab-N-807 by clicking the link below or browse more documents and templates provided by the California Department of Public Health.

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Download Form Lab-N-807 "Request for Psp Testing - Environmental Management" - California

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Environmental Management - Request for PSP Testing
[ ] Check here if Sample Tracking in Lab is needed for Chain of Custody
Submitter:
Collector:
County:
Date:
Time:
Address:
Shellfish Species:
[ ] oyster
Shellfish Collection Site:
[ ] mussel
([bay, sea], [sentinel, cultured])
[ ] other ________________
Bottle cap#
[ ]
Authority
Commercial Grower
[ ] Volunteer
[ ] Other
[ ] EMB (Pre-harvest)
[ ] FDB (Post-harvest)
Analysis
[ ] PSP
[ ] Other toxin _____________________
For Laboratory Use Only
Shipped Date: [
]
Unpacked by
Received Date & Time
Temperature on lab arrival
[ ] Warm
[ ] Cold
[ ] Frozen
[ ] DHL [ ] UPS [ ] FedX [ ] Hand
o
(______
C)
[ ] USPS [ ] GoldenState [ ] Other
[ ] Sample was not tested - EMB contacted for replacement sample
Sample Notes [ ] Integrity compromised
[ ] Leaked in transit [ ] #Animals <12 [ ] Quantity <100 g [ ] Other ____________
[ ] Spoiled [ ] Temperature >10.5 C [ ] Transit time >24 hr
Results
[ ] Neg
[ ] Not Tested
EMDS No.
PSP Jellett Test:
PSP Mouse Bioassay in ug/100 g
[ ] Invalid [ ] Pos
Result Notes:
[ ] Results are Not for Regulatory Use; sample fails quantity or quality criteria for NSSP
[
/3 ] Mice sick
[ ] Animal symptoms are inconsistent with PSP
[ ] Animal symptoms resemble domoic acid
Comments:
________________________________________________________________________________________________
____________________________________________________________________________________________________________
[ ] Sample was transferred to _____________
[ ] Archive saved
[ ] No archive
Analyst:
QC/QA reviewed:
Sup reviewed:
Results phoned to:
Initials/date
Initials/date
Initials/date
Date
Time
By
Computer entry [ ] Done
Electronic transmission [ ] Done
Lab-N-807e.psp.062813
California Department of Public Health, Microbial Diseases Laboratory, 850 Marina Bay Parkway, Richmond, CA 94804
Environmental Management - Request for PSP Testing
[ ] Check here if Sample Tracking in Lab is needed for Chain of Custody
Submitter:
Collector:
County:
Date:
Time:
Address:
Shellfish Species:
[ ] oyster
Shellfish Collection Site:
[ ] mussel
([bay, sea], [sentinel, cultured])
[ ] other ________________
Bottle cap#
[ ]
Authority
Commercial Grower
[ ] Volunteer
[ ] Other
[ ] EMB (Pre-harvest)
[ ] FDB (Post-harvest)
Analysis
[ ] PSP
[ ] Other toxin _____________________
For Laboratory Use Only
Shipped Date: [
]
Unpacked by
Received Date & Time
Temperature on lab arrival
[ ] Warm
[ ] Cold
[ ] Frozen
[ ] DHL [ ] UPS [ ] FedX [ ] Hand
o
(______
C)
[ ] USPS [ ] GoldenState [ ] Other
[ ] Sample was not tested - EMB contacted for replacement sample
Sample Notes [ ] Integrity compromised
[ ] Leaked in transit [ ] #Animals <12 [ ] Quantity <100 g [ ] Other ____________
[ ] Spoiled [ ] Temperature >10.5 C [ ] Transit time >24 hr
Results
[ ] Neg
[ ] Not Tested
EMDS No.
PSP Jellett Test:
PSP Mouse Bioassay in ug/100 g
[ ] Invalid [ ] Pos
Result Notes:
[ ] Results are Not for Regulatory Use; sample fails quantity or quality criteria for NSSP
[
/3 ] Mice sick
[ ] Animal symptoms are inconsistent with PSP
[ ] Animal symptoms resemble domoic acid
Comments:
________________________________________________________________________________________________
____________________________________________________________________________________________________________
[ ] Sample was transferred to _____________
[ ] Archive saved
[ ] No archive
Analyst:
QC/QA reviewed:
Sup reviewed:
Results phoned to:
Initials/date
Initials/date
Initials/date
Date
Time
By
Computer entry [ ] Done
Electronic transmission [ ] Done
Lab-N-807e.psp.062813
California Department of Public Health, Microbial Diseases Laboratory, 850 Marina Bay Parkway, Richmond, CA 94804