Form Lab-N-801 "Request for Laboratory Services - Drinking and Recreational Waters" - California

What Is Form Lab-N-801?

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-801 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-801 "Request for Laboratory Services - Drinking and Recreational Waters" - California

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Rate (4.6 / 5) 44 votes
Request for Laboratory Services -
Drinking and Recreational Waters
D
Check here
if
Sample Tracking in Lab is needed for Chain of Custody
.
- ~ ·
Submitter:
Collector:
County:
Date:
Time:
Address:
Sample: D Regulatory
Status:
D First submission
D Non-regulatory
D Repeat
D Other
D Replacement
Phone:
Drinking_ Water Source
Test/Anal~sis
0Chlorinated/Disinfected
Duntreatect
DPresence/ Absence
DEnumeration
0Pre-distribution
DDistribution
0Coliforms (circle: Total
I
Fecal
I
Ecoli)
D Surface water
DGroundwater
DGround w Surface Influence
Recreational Water
DOther
D
Marine or Estuary
D Freshwater
DOther
Other
DOther
Bottle Cap#
I
Collection Point/Sample Site
Sample Preservation - Field Treatment
DNone
Diced
DSodium thiosulfate
DAcidified
DOther
Special instructions:
Shipped Date: [
Unpacked by
Received Date & Time
Temperature on lab arrival
O
Warm
O
Cold
D
Frozen
(_'C)
0DHL OUPS
OFedX DHand
OUSPS 0GoldenState 00ther
Condition Notes: D Exceeded transit time (a)
DOther
-
'
'
" '
D
~pN~A~ency con
EMDSNo
(d)
Condition
Notes
Dintegrity compromised (b)
DLeaked in transit ( c)
Total
Coliform(!)
DTemperature >10 C (f)
Fecal
Coliforrn<
1 l
E. col;i'l
Colony
Count'')
Circle: - unit of
measurement
MPN
cfu
MPN
cfu
MPN
cfu
MPN
cfu
(1) MPN or cfu per 100 ml for enumeration; Presence=P or Absence=A per 100 ml
(2) Heterotrophic Plate Count as cfu per ml
(3) Test Methods: F=Fermentation; D=Defined substrate; M=Membrane Filter; R=R2A agar; P=Plate count agar; O=Other
Notes:
Test
Method
3
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Analyst:
QC/QA reviewed:
Sup reviewed:
Results phoned to:
Initials/date
Initials/date
Initials/date
Date
Time
By
Computer entry DDone
I
Electronic transmission DDone
Lab-N-80 I. water.06.28 .13
.
-----·
--
Californifilepartmenfllf Public Health, Microbial Diseases Laborat(l'1';;fo
Marimi}JitY
Barkway;.:~M.l'a;cA 94804
. .
Request for Laboratory Services -
Drinking and Recreational Waters
D
Check here
if
Sample Tracking in Lab is needed for Chain of Custody
.
- ~ ·
Submitter:
Collector:
County:
Date:
Time:
Address:
Sample: D Regulatory
Status:
D First submission
D Non-regulatory
D Repeat
D Other
D Replacement
Phone:
Drinking_ Water Source
Test/Anal~sis
0Chlorinated/Disinfected
Duntreatect
DPresence/ Absence
DEnumeration
0Pre-distribution
DDistribution
0Coliforms (circle: Total
I
Fecal
I
Ecoli)
D Surface water
DGroundwater
DGround w Surface Influence
Recreational Water
DOther
D
Marine or Estuary
D Freshwater
DOther
Other
DOther
Bottle Cap#
I
Collection Point/Sample Site
Sample Preservation - Field Treatment
DNone
Diced
DSodium thiosulfate
DAcidified
DOther
Special instructions:
Shipped Date: [
Unpacked by
Received Date & Time
Temperature on lab arrival
O
Warm
O
Cold
D
Frozen
(_'C)
0DHL OUPS
OFedX DHand
OUSPS 0GoldenState 00ther
Condition Notes: D Exceeded transit time (a)
DOther
-
'
'
" '
D
~pN~A~ency con
EMDSNo
(d)
Condition
Notes
Dintegrity compromised (b)
DLeaked in transit ( c)
Total
Coliform(!)
DTemperature >10 C (f)
Fecal
Coliforrn<
1 l
E. col;i'l
Colony
Count'')
Circle: - unit of
measurement
MPN
cfu
MPN
cfu
MPN
cfu
MPN
cfu
(1) MPN or cfu per 100 ml for enumeration; Presence=P or Absence=A per 100 ml
(2) Heterotrophic Plate Count as cfu per ml
(3) Test Methods: F=Fermentation; D=Defined substrate; M=Membrane Filter; R=R2A agar; P=Plate count agar; O=Other
Notes:
Test
Method
3
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Analyst:
QC/QA reviewed:
Sup reviewed:
Results phoned to:
Initials/date
Initials/date
Initials/date
Date
Time
By
Computer entry DDone
I
Electronic transmission DDone
Lab-N-80 I. water.06.28 .13
.
-----·
--
Californifilepartmenfllf Public Health, Microbial Diseases Laborat(l'1';;fo
Marimi}JitY
Barkway;.:~M.l'a;cA 94804
. .