ST8804-LR 910214 (2)WATER BACTERIOLOQ~ /' ' * T nme~tol Health
Focm No. ~-19 (rev. 1~) ' IurHu of ~ll~ -;,
OIte
Date and Time R~d
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~NT OF COLLECTION COLLECTED ~Y - MONTH DAY YEAR TiME . ~M;~
TYPE OF SYSTEM ~pu~,c Sys~em~O~y~ ,,WATER BOURCE
~ Public ~ Dairy ~ Distribution /~ Raw '"~ River ~ ~ke
~ Individual ~ Bottled ~ ~nltructlo~ ~ ~lck "; ~ ~elt Well ~pth
._ Chlorine Re.ldual
Ownership or other information:
LABORATORY REPORT (~ ~1 ~te
Water of satisfactory baoterlologlcal quality ahould ~ free from ~llform organisms
~ Date discrepancy or fo~ Incomplete ~ Henw {~lltl~ncterlnl growth) (with collfom~) p~esent, '~
(See encircl~ item) ~;.ibly ~curing nad comproml;ing te~t results ..]~
~ Qunntlty Insufficient tot annlysl~ ~ Qunntlty t~ great to ~ermit agitation :'
~ Lenk~ln ttln.lt ~ Other :-J
~ Not an appmv~ contBlner -