Sample No.:______RESULTS

OHIO Water MICROBIOLOGY LABORATORY

ANALYTICAL SERVICES REQUEST FORM

Ship samples to Attn: OWML, 6460 Busch Blvd. Suite 100, Columbus, OH 43229; 614/430-7772

Station Name: ______

Site Number: ______

Date: __ __ / __ __ / ______Time: ______Medium Code: ______Sample Type: ______

M M D D Y Y Y Y

User Code (WSC where data should be sent): ______NAWQA SUCODE: ______

(Examples: OH, KY, CA2, FL4) (If applicable)

FBMS WBS Element: ______Contact: ______

(Fill in with local account number) (Name and phone number)

Sample bottle conditions: [ ] Bagged? [ ] Lid on? [ ] Sterile - autoclave tape?

Sampling Conditions:______

(Examples: inside/outside, windy, rainy, pets/livestock nearby)

Sample analyses (check off all that apply):

Coliphage (E. coli Famp and CN-13 hosts): / Culture methods:
[ ] / Single-agar layer, quantitative, Method 1602 (1 L) / [ ] / Actinomycetes (AIA)
[ ] / Enrichment, presence/absence, Method 1601 (3 L) / [ ] / Aerobic endospores (NA+TBl)
[ ] / Matrix spike, presence/absence, Method 1601 (6 L) / [ ] / E. coli and total coliforms (Colilert QuantiTray 2000)
[ ] / E. coli (modified mTEC)
Microbial source tracking markers (qPCR): / [ ] / Enterococci (mEI)
[ ] / General (AllBac) / [ ] / Enterococci (Enterolert QuantiTray 2000)
[ ] / General (GenBac) / [ ] / Clostridium perfringens (mCP)
[ ] / Human (HF183) / [ ] / Other: ______
[ ] / Canine (BacCan )
[ ] / Ruminant (Rum2Bac) / Viruses:
[ ] / Cattle (CowM2) / [ ] / Enteric viruses (cell culture)
[ ] / Waterfowl (GFD) / [ ] / Enterovirus and Norovirus GIA, GIB, GII (qRT-PCR)
[ ] / Other: ______/ [ ] / Adenovirus (qPCR)
[ ] / Human polyomavirus (qPCR)

Sample/cooler conditions – lab use only (check off all that apply):

[ ] / Cold / [ ] / Bottle(s) broken
[ ] / Cool (some ice melted) / [ ] / Bottle packed separately from ice
[ ] / Warm (ice melted completely) / [ ] / Liquid in bag with sample
[ ] / Bottles intact / [ ]

Sampled by ______Shipped by ______Date shipped ______

Received by ______Date received ______

Coliphage Analyses / Method / Parameter Code / Result / Units / Rem / VQ / NVQ
Method 1602 / E. coli Famp / quantitative / 90904 / PFUs/100 mL
E. coli CN-13 / quantitative / 90903 / PFUs/100 mL
Method 1601 / E. coli Famp / enrichment / 99335 / # / P/A per 1 L
E. coli CN-13 / enrichment / 99332 / # / P/A per 1 L

[Method 1601 key: in result, enter “#”; in remark, enter “M” for positive or “U” for negative]

Coliphage Analysis Date: ______Results Read By: ______Date Read:______

Bacterial Analyses / Matrix / Parameter Code / Result / Units / Rem / VQ / NVQ
Actinomycetes (AIA) / Water / 63688 / CFU/mL
Aerobic endopspores (NA+TBl) / Water / CFU/100mL
Escherichia coli
(modified mTEC) / Water / 90902 / CFU/100mL
Sediment / 63156 / CFU/gdw
Escherichia coli
(Colilert Quantitray 2000) / Water / 50468 / MPN/100mL
Sediment / 50467 / MPN/gdw
Total coliforms
(Colilert Quantitray 2000) / Water / 50569 / MPN/100mL
Sediment / MPN/gdw
Enterococci (mEI) / Water / 90909 / CFU/100mL
Sediment / 63157 / CFU/gdw
Enterococci
(Enterolert Quantitray 2000) / Water / 99601 / MPN/100mL
Sediment / MPN/gdw
Clostridium perfringens
(mCP) / Water / 90915 / CFU/100mL
Sediment / CFU/gdw
Other:
Molecular and Cell Culture Analyses
Marker / Results / Units / Organism / Results / Units
AllBac / copies/100 mL / Enterovirus / copies/L
GenBac / copies/100 mL / Norovirus GΙA / copies/L
HF183 / copies/100 mL / Norovirus GΙB / copies/L
BacCan / copies/100 mL / Norovirus GΙΙ / copies/L
Rum2Bac / copies/100 mL / Adenovirus / copies/L
CowM2 / copies/100 mL / Human polyomavirus / copies/L
GFD / copies/100 mL / Total culturable virus / MPN/L