FORM XVII
[Rule 24]

    

Report of Insecticides Analyst _________________              Sl.No.__________

     1.  Name of the Insecticides Inspector, from whom samples have been
          received.________________________________________________

     2.  Serial No. and date of Insecticides Inspector's memorandum.__________

     3.  Number of the sample._____________________________________

     4.  Date of receipt.__________________________________________

     5.  Name of the insecticides purporting to be continued in the sample  .
          _________________________________________________

     6.  Condition of the seals on the package; state whether :-

               i.    The sample was properly sealed and fastened

               ii.   The seal was intact and unbroken.

               iii. The seal fixed on the container and the outer cover of the sample
                    tallied with the specimen impression of the seal separately sent by
                    the Insecticides Inspector; and

               iv. The sample was in a condition fit for analysis.

      7.  Date of the test or analysis.__________________________

      8.  Result of test or analysis with protocols of test applied.______________

Verification

I certify that I have analyzed / caused to be analyzed the aforementioned sample, and declare the result of analysis to be as above.


Signed this ________________ day of __________20_______________.

 

 

 

(signature with seal)
Insecticide Analyst