Form X
Report by the Central Board Analyst
(See rule 26)

Report No………………
Dated the 19……………
I hereby certify that 1, (I)………….Central Board analyst duty appointed under Sub-section (3) of Sec. 53 of the Water (Prevention and Control of Pollution) Act, 1974 (6 of 1974) received on the (II) …………. day of………. 19……. from (III)……a sample of (IV)………….for analysis. The sample was in a condition fit for analysis reported below :
(V)....................................................................................................
The condition of the seals, fastening and container on receipt was as follows:
....................................................................................................................................
Signed this……………day of……………19…………
(Signature)
Central Board Analyst
Address..................................
To..................................................
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(I) Here write the full name of the Central Board Analyst.
(II) Here write the date of receipt of the sample.
(III) Here write the name of the Board or person or body of persons of officer from whom the sample was received.
(IV) Here write the details of analysis.
(V) Here write the details of the analysis and refer to the method of analysis. If the space is not adequate the details may to given on a separate sheet of paper.