Alford Media-LR 980209~ T:/~!ANT COUNTY PUBLIC HEALTH LABOR .A~? ~
',~"";, L.~. ~ 1800 Univer~ Dr., Ft. Worth, TX 76107
BACTERIOLOGY L,b No. 48010 (817)871-7245
Date and Time ,~.,_'~1~
'l~porte~
Sample No.
SEND
RESULTS
TO:
Do Not Mark Above This Line .-...Please Print Below with BALLPOINT PEN OR TYPEWRITER:
NAME OF WATER SYSTEM /
POINT OF COLLECTIONISAMPLE DESCRIPTION
' NAIdE
STREET ADDRESS ¢.0. Box} '
CiTY
PHONE #
Date and
Water System i.D. No.
TX ~ - '~r'~ '/
(Zip Code)
I/I, I: Ixll
Time et
Collection Month
Day Year TIME 'AMIPM Collected By
WATER SOURCE
i-lRiver ~Lake
[-Iw~
Well Depth
Chlorine Residual
TYPE OF SYSTEM
lic r--IDairy
ndividual [] Bottled
[]School []Vended
SAMPLE IS
[]Distribution []Raw
/Jr_l~l_lCenstruction [] Repeat
Glycol[Sweet[Chill Water
[-10ther
Additional Information:
LABORATORY REPORT ldo no twrite below)
TECH
MMO.MUG
,PreeancetAbsence
Colifor~Qrganisms
[] Not FOund
[] Found .,
[] Total Coliform group
[] £scl~ricAb col~
Membrane Filtration (MF)
Coliform Organisms
[] Not Found
[] Found
Total Coliform/100 mi
E. col~/ I O0 mi
,C~,[] Repeat samples required
Unsuitable -- See below
Fecal ColiformsllO0 mi
[] Unsuitable -- See below
MMO-MUG
Most Probable Number (MPN)
Coliform Organisms
[] Not Found
[] Found
Total
Coliform: MPNIIOOml
E. coli: MPNIIOOml
[] Unsuitable -- See below
UNSUITABLE FOR ANALYSIS-PLEASE RESUBMIT
[] Sample too old. Sample net received []
within 30 hours of collection
[] Date discrepancy or form incomplete / []
(See encircled item)
[] Leaked in transit []
/~ Quantity too great to permit agitation []
Excessive chlorine residual: ~ I ~omg/L
Quantity insufficient for analysis
(100 nd. required)
Heavy (silt~bacterial growth) present,
possibly compromising test results
Sample received on Friday
Other
H-220 GPC-2190
REV. 6-97
~:' . ?~!ANT COUNTY PUBLIC HEALTH LABOR~"~Y
~ ''~--~"- ~" 1800 Unive~s~ Dr., Ft. Worth, TX 76107
WATER BACTERIOLOGY · LobBo. 48010 (811)871-7245
Date and Tim~c'~ ] ~ ~-~ Q" F~Q~tP ~ ~ ~" ~ ~
Sa~le No. Rpo~ed
Do Not Mark Above This Line .....Please Print Below with BALLPOINT PEN OR TYPEWRITER:
BAME OF WATER SYSTEM
POIBT OF COLLECTION/SAMPLE DESCRIPTION
RA~E
RESULTS STREET ADDRESS (P.O. Box}
.,, TO: ')~':~ _
Water System I.D. No.
(Zip Code)
COUNTY
0;.::;" Io1 110 IL? I 1 -I: Io1 1 I KI
Collection Month Day Year TIME AM/PM
TYPE OF SYSTEM SAMPLE IS
Pubiic i'-IDairy E;] Distribution [-'1Raw
individual [-1 Bottled ;'~Censtruction ' r-]Repeat
r'-lSchool I--IVended /'r'~r-lGiycoUSweetlChill Water
I--lOther
Additional Information:
MMO-MU6
Presence/Absence
Coliform Organisms
[] Total Coliform group
[] EscAerichia chi
[] Repeat samples required
[] Unsuitable -- See below
Collected By
WATER SOURCE
r-lRiver ~Lake
I-lWeU
Well Depth
Chlorine Residual
LABORATORY REPORT ldo no write belowl
Membrane Filtration (MF)
Coliform Organisms
[] Not Found
[] Found
Total Coliform/100 nd
£.co/i/100 mi
Fecal Coliforms/lO0 mi
[] Unsuitable -- See below
TECH
MMO-MUG
Most Probable Number (MPN)
Coliform Orgonisms
[] Not Found
[] Found
Total
Coliform: MPN/IOOml
E. co/~' MPNIIOOnd
[] Unsuitable -- See below
UNSUITABLE FOR ANALYSIS-PLEASE RESUBMIT
[] Sample too old. Sample not received
within 30 hours of collection
[] Oate discrepancy or form incomplete
(See encircled item)
[] Leaked in transit
[] Quantity too great to permit agitation
[] Excessive chlorine residual: .mg/L
[] Ouontity insufficient for analysis
(100 mi. required)
[] Heavy (silttbacterial growth) present,
possibly compromising test results ,
[] Sample received on Friday
[] Other
H-220 GPC-2190
REV. 6-97