FORM XI Report by the Government Analyst See rule 27 Report No ______________ Dated the ________ 19____ I hereby certify that I, (I) ______________ Government analyst duly appointed under sub-section (1) 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 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 ________ 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 persons or body of persons of 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 the details may be given on separate sheet of paper. | 