Form XI
Report by the Government Analyst
(See rule 27)

Report No
Dated the 19.
I hereby certify that I, (I)………..Government analyst duty appointed under sub-section (I) 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……….. for analysis. The sample was in a condition fit for analysis reported below:
I further certify that I have analysed the aforementioned sample, on (IV)………..and declare the result of the analysts to be as follows:
(V)........................................................................................................
The condition of the seals, fastening and container on receipt was as follows:
...............................................................................................................
Signed this……….. day of………… 19.
(Signature)
(Government Analyst)
Address……………………….
To……………………..........
(I) Here write the full name of the Government 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 the 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 be given on separate sheet of paper.