Rosebriar-LR121023 (2) DRINKING WATER (P/A) COLIFORM SUBMISSION/REPORT FORM • z.•. Tarrant County Public Health ",,
Q,,„�",_�.,., •North Texas Regional Laboratory
Y Sample (Please type print) t4 rte . °�
Public/Private Water System Identification&Sam ie Collection Information Please t e or use block rint �tR 1101 South Main Street,Suite 1700 ,' "�a
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Public Water System ID: .. - Fort Worth,TX 76104 NELAC Certificate#:
(Must be 7 digits;include all zeros) " Phone (817)321-4778 7104704339-TX
Public Water
* ' *' Fax(817)321-5378 Test results meet all requirements of
System Name: �, I i +Ll C TCEO Lab ID:48010)USEPA Lab ID:01471 NELAC unless stated otherwise.
�.,,_ LABORATORY USE ONLY-DO NOT MARK TO THE RIGHT OF THE BOLD CENTER LINE
County: �ff.11, } :. qsi r_ ! ' `1 -� �" Sample Iced?
! Received Date/Time .' r 4,L 14.
o Name: 7 n ry t„ L.�- Yes No By: Received: "`ter
3 Address: If no,temperature Tested ! Date/Time
tj 22712
e) at receipt? By: Tested: 'L.F�-+ "
-0 City: ,, j- t,Af n .I ;
C o Reported ( ,Date/Time ,_'�ppi�.t+•� r} 4/q py9
N State: Zip: I I , I C By: i Reported: fiJR r l 4 h1t(1 tF"i 1
Phone#: i y : .7` L -2-,.. Fax#: ,r� -4Z) } 1 4 Z Report Approval `�`
`� Signature: t r VA
Sampler Name: r {. C`--4_-- _
IC I Terry Jan �``�,,__
Approving ❑ Bacon ❑ Hudler
Date of E rya 7 Pri y{ 1
Sampler Contact#: ❑ Owner ❑ Operator III Other: Technical ,AA L 3 L i 1 'i"31 i
Director: Diane Nancy Approval:
System Type: (Al) Water Source: ('I) ❑ Hardin ❑ Turnage
Public I 'Private I IBottledNended Groundwater(Well) I [Surface Water(Lake,river) Chlorine Lab Results
Unsuitable
Other: Groundwater with Surface Water Influence Residual Sample- Note:All test results relate only to the samples as received. Laboratory
I Sample Identification Collected Sample Type• (til) II Free Please Test Method: SM9223 Sample
Use Specific Address/Location/Description Date Time Include Lab ID of Resubmit`
mg/L Colilert-18 Presence-Absence Format ID
-° t m Previous Positivgi
DO NOT USE SITE# _0 2 d a I on All Samples Total Coliform E.coli
m Please circle 2 113 3 n Total Rejection Number
Raw Wells Use Source ID for Well Sampled;Ex.G1234567A o CI } AM or PM 8 o cn Related to the mg/L Criteria#
} o Original Sample g Present Absent Present Absent
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Coliform P/A *Unsuitable Sample Analysis- 1) Sample Too old. Not received within 24 hours of collection 3) Excessive Chlorine Residual(>10 mg/L) 5) Form Incomplete/Date Discrepancy(Errors Circled)
Form:8/2009 :Rejection Criteria#Definitions 2) Quantity insufficient for analysis(100mL required) 4) Heavy Silt/Turbidity Present 6) Other: