The Water (Prevention and Control of Pollution) Rules, 1975 - Form XI

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(See rule 27)

Report No:

I hereby certify that 1, (I) ___________ Government analyst duly appointed under sub-section (I) of section 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 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:-



The condition of the seals, fastening and container on receipt was as follows:-


_______________________________________ signed this __________ day of __________ 19

(Government analyst)

Address ____________________________



(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 or officer from whom the sample was received.

(IV) Here write the date of analysis.

(V) Here write the details of the analysis and refer to the method of analysis. If the space is not adequate and details may be given on a separate sheet of paper.

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