POOL BACTERIA FORM

Pool Water Bacteria Sample Testing (Lab#: UT00955)
620 S 400 E #400, St George, UT 84770 | 435-986-2580
All test results are sent via email

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Samples Collected By :

Collection Date :

Send Reports To:

Company Name :

Phone :

Email :

Address:

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SAMPLES MUST BE RECEIVED BY THE LAB WITHIN 24 HOURS OF COLLECTION TIME

Pool Type: (P) Pool, (S) Spa, (O) Other \| Sample Type: (Rtn) Routine, (Rpt) Repeat, (Chk) Check										[Lab Use Only]
Pool Location Name	Pool Type	Sample Time	Bottle ID	Sample Type	pH	Free Cl₂	Total Cl₂	CYA	Bathers Present	Sample #	Coliform	E. coli	HPC MPN
	PSO			RtnRptChk							+ / –	+ / –
	PSO			RtnRptChk							+ / –	+ / –
	PSO			RtnRptChk							+ / –	+ / –
	PSO			RtnRptChk							+ / –	+ / –
	PSO			RtnRptChk							+ / –	+ / –
	PSO			RtnRptChk							+ / –	+ / –
	PSO			RtnRptChk							+ / –	+ / –
	PSO			RtnRptChk							+ / –	+ / –
	PSO			RtnRptChk							+ / –	+ / –
	PSO			RtnRptChk							+ / –	+ / –

I, Full Name Statement Declaration declare the samples remained in my possession and the information submitted on this form is true, accurate, correct and complete.

Date:

Time:

Signature:

Chain of Custody [Lab Use Only]

Paid:

Lab Rcvd By:

Date:

Time:

Accessibility Notice: If you need assistance or an alternative format to complete the form, email info@swuhealth.gov. Notice for Public Personal Data Collection at: swuhealth.gov/public.

Updated: 10/27/2026

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POOL BACTERIA FORM

Pool Water Bacteria Sample Testing (Lab#: UT00955)620 S 400 E #400, St George, UT 84770 | 435-986-2580All test results are sent via email

Pool Water Bacteria Sample Testing (Lab#: UT00955)
620 S 400 E #400, St George, UT 84770 | 435-986-2580
All test results are sent via email