ESR1130 - LABORATORY SERVICES REQUEST FORM WATER MICROBIOLOGY SAMPLE SUBMISSION

CLIENT INFORMATION BUSINESS NAME AND ADDRESS FOR REPORTING Name of sampler: Name: Organisation name: Address: Client order No: Job No: Contact name: Date sent: Email: TYPE OF SAMPLE Please tick appropriate box Phone: Drinking water Effluent Email for invoice if different from above: Non potable water Saline recreational water Swimming/Spa pool Fresh recreational water ESR USE ONLY Other (specify):. [...] Date and time Water sample information sampled ESR use only Client Ref Name of supply point (select from dropdown menus under each column No. [...] Compulsory (please supply code in field under supply point) or write number from the table below) must be filled in Source Type Treatment FAC CODE: CODE: CODE SOURCE OF SUPPLY TYPE OF SUPPLY TREATMENT 1 Well/Bore 5 Roof runoff 8 Spring Head 12 Chlorination 15 Filtration 2 River, Stream 6 Spring 9 Well Head 13 Ultra Violet 16 Coagulation 3 Water race/Canal 7 Gallery 10 Building Reticulation 14 Ozon. [...] WATER Date and time Water sample information sampled (select from dropdown menus under each ESR use only Client Ref Name of supply point No. [...] Compulsory (please supply code in field under supply point) column or write number from the table below) must be filled in Source Type Treatment FAC CODE: CODE: CODE: CODE: CODE: CODE: CODE: CODE: CODE: CODE: CODE: CODE: CODE: CODE: SOURCE OF SUPPLY TYPE OF SUPPLY TREATMENT 1 Well/Bore 5 Roof runoff 8 Spring Head 12 Chlorination 15 Filtration 2 River, Stream 6 Spring 9 Well Head 13 Ultra Violet 16.