Field ID Number	New Jersey Department of Health

Sanitary Bacteriology Laboratory

PO Box 361, Trenton, NJ 08625-0361

Phone: 609-530-8395

BACTERIOLOGICAL SAMPLE SUBMITTAL	Lab Sample Number

(For Lab Use Only)
(See Instructions)

AGENCY INFORMATION
Submitting Agency

Send Results To

Agency No.

Project Name

Street Address

Final Report Option

Tier 1 Tier 2	Would you like copies of the internal chain of custody forms sent with your report?

Yes No	Project Code

Electronic Report Option

EDD E-2
Memo Number

City, State, Zip Code

Phone

Fax

Email

SAMPLE INFORMATION
Facility ID/Sample Point/Station ID Number

Collection Date (YY/MM/DD)

__ __ / __ __ / __ __	Sample Type

Non-Potable:

Stream/Surface	Tissue

Ground Water	Sewage:

Private Well	Raw Effluent

Septic	Industrial:

Ocean/Saline	Raw Effluent

Sediment

Potable:

Groundwater Rule	At Source

Source	Flushed

Confirmation	1st Draw

Raw	Lead Source Line

Finished	Surface H2O Intake

Private Well	Distribution System

Fraction:	Total Dissolved

Other:	________

Priority:	Routine Priority Emergency
Sampling Point ID/Sampling Site/Facility/Supply/Location

Coll. Time (24h) Start	Coll. Time (24h) End

__ __ __ __	__ __ __ __
Waterbody Name

Sample Retention

Retain? No Yes Duration ________
Municipality/County

Type of Sampling Event

Regular Compliance Repeat

Non-Regulatory Other
Sampling Point Street Address

If Repeat or GWR, List Original Lab Sample No.

Sample Collector

PWSID

Trip #

FIELD INFORMATION
Air Temp °C

Water Temp °C

Stream Flow-CFS

Weather Conditions

Sample pH (Field)

Gage Height-Ft.

Preserved in: Field Lab

Date: __ __ / __ __ / __ __

Time: __ __ __ __	DO (mg/l)

Spec.Cond. (µS/CM)

DO% Sat

Salinity (ppm)

Rain Events

Rain in the last 24 hours? Yes No

Rain in the last 48 hours? Yes No	Sample Depth Ft.

Tide Stage

Barometric Pressure (mmHg)

Turbidity (NTU)

Comments

Chlorine Residual

ANALYSIS REQUESTS
Suggested Dilutions
Fecal Coliform / 100 ml	MPN SM9221E

10

1

-1

10

-2

10

-3

10

-4

10

-5

10

-6

10	Total Coliform & E.Coli / 100 ml	P/A (Colilert) SM9223B
Fecal Streptococci / 100 ml	MPN SM9230B

10

1

-1

10

-2

10

-3

10

-4

10

-5

10

-6

10	Enterococci / 100 ml	Idexx Enumeration (Enterolert)

(Non-Drinking Water)
Enterococci / 100 ml	MPN SM9230B

10

1

-1

10

-2

10

-3

10

-4

10

-5

10

-6

10	E.Coli / 100 mL	Enumeration (Colilert)

(Non-Drinking Water) SM9223B
Total Coliform / 100 mLs	MPN SM9221B

10

1

-1

10

-2

10

-3

10

-4

10

-5

10

-6

10	SPC/HPC/ml	SM9215B
Relinquished By:	Affiliation:	Received By:	Affiliation:	Date/Time	Reason for Custody Change

Name (Print): _________________________	Name (Print): _________________________

Signature: ____________________________	_____________	Signature: ____________________________	_____________	__________	_______________

Name (Print): _________________________	Name (Print): _________________________

Signature: ____________________________	_____________	Signature: ____________________________	_____________	__________	_______________
BACT-44

DEC 16

BACT-44, Bacteriological Sample Submittal

BACT-44, Bacteriological Sample Submittal, sanitary bacteriology, laboratory, water

ewhite

2016-11-25

NJDOH