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Air (Prevention and Control of Pollution) Rules, 1983

CENTRAL POLLUTION CONTROL BOARD
FORM IV

REPORT BY THE CENTRAL BOARD ANALYST
(See rule 14)

Report No. ….…..
Dated the …...…..

I hereby certify that I, (I) ……………........................ Central Board analyst duly appointed under sub-section 3 of section 26 of the Air (Prevention and Control of Pollution) Act 1981, 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 analysis to be as follows:- (V) ……………........................……………........................

The condition of the seals, fastening and container on receipt was as follows:-
……………........................……Signed this ………................... day of ………...............20……….....

(Signature)
Central Board Analyst

Address…………………………
……………………………………….
……………………………………….
……………………………………….

To
……………………………………….
……………………………………….
……………………………………….

  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 or persons or officer from whom the sample was received.

IV. Here write the date of analysis.

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 a separate sheet of paper.

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