Cambridge Phase 2-LR 970205Fcffm No. O19 (R~'<V93)
Date and Time Recu. Date
Sample No. _~ 4F£B 18=19 .q_?e225 Reported ,
Do not mark above this line ~ Please print with ballpoint pen or t~pewriter.
Water System I.D. N~3~ ^ '.. ~ _ ,,NAME OF W~TER SYSTEM
/~o~-~" #~ o4 ('~'-/~ C'~z=~=Y-.-
' cOUNTY
POINT OF COLLECTIONI I
Submitter I.D. No. IIIIIII
SEND (tin II Il u] ,~,'lt I~1451~1 I I I I I I i I I I I I I I I I I I
NAME
STREET ADDRESS (P.O. Box)
CITY ZIP CODE
Date and
· ,~e o,
Collection DAY
MONTH YEAR TIME AM/PM
SAMPLE 1S
TYP~ OF SYSTEM (Public Systems Only)
-[~Pi~blic- [] Dairy [] Distribution [] Raw
[] Individual [] Bottled E~onstruction [] Repeat
Ownership or other information:
,Department of Health
u of Laboratories
COLLECTED BY
WATER SOURCE
[] River [] Lake
[] Well Well Depth.
[] Special ',' , 'r -,_ Ch~rine Residual
LABORATORY REPORT (Do not write below)
Water of satisfactory,,~',i,-~{°l°gical quality must be free from Coliform organisms
F~J. nd*~ ~ ~ \~-,
Coliform Organisms JZ3d~Ut J ~ ---.
~[] Found ..........
[] Total coliform group
[] Escherichia coil
[] Repeat samples required
[] Unsuitable -- See below
~ I~UNICIPAL I-ABORA'rOR¥
L~,,&t, NUMBER 48130
UNSUITABLE FOR ANALYSIS - PLEASE RESUBMIT
[] Sample too p~ld. Sample not received [] Quantity insufficient for analysis
within 30 hobrs of collection (100 mi. required)
[] Date discrepancy or form incomplete [] Heavy (silt/bacterial growth) present,
(See encircled item) possibly compromising test results