FORM XX
INTIMATION TO PERSON/ LICENCEE FROM WHOM
SAMPLE IS TAKEN
[Rule 33]

To
___________________________
____________________________

I have this day taken from the premises of _____________________ situated at ______________ samples of the insecticides specified below for the purposes of test or analysis.

 

Date._________________                                               Insecticides Inspector


Details of samples taken_____________________________


Date._________________                                               Insecticides Inspector