FORM IX
REPORT OF INSECTICIDE ANALYST
[Rule 24(3)]

     1.  Name of the insecticide inspector from whom received. ___________________

     2.  Serial No. and date of Insecticide Inspector's Memorandum.________________

     3.  Number of sample.______________________________________________

     4.  Date of receipt._________________________________________________

     5.  Name of the insecticide purporting to be contained in the sample.____________

     6.  Condition of the sales on the package.________________________________

     7.  Result of test or an analysis with protocols of test applied.__________________

 

Insecticide Analyst.

Date.__________________