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DRINKING WATER (P/A) COLIFORM SUBMISSION/REPORT FORM z ,.. Tarrant County Public Health Test COt71Vr
. ., - •. North Texas Regional Laboratory requirements
Public/Private Water System Identification&Sample Collection Information(Please type or use block print). r4�4*` a: 1101 South Main Street,Suite 1700 of NELAC
Public Water System ID: at %m Fort Worth,TX 76104 unless stated
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(Must be 7 digits;include all zeros) AI t Phone (817)321-4778 otherwise.•
Public Water r •••• •.*. *•• Fax(817)321-5378 NELAP Certificate#:
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System Name: I „ ""; , y TCED Lab ID:460101 USEPA Lab ID:01471 7104704339-12-4
County: I P 4011
LABORATOAY USE ONLY-DO NOT MAR1 Q THE MONT OF THE BOLD CENTER LINE
J /*Af J Sample Iced?
Received Date/Time .{'] 4
O
Name: h a Yes No By: ReCeiv¢d: F "13 2:54
Address: `°•r'�, It no,temperature Tested Date/Tithe
N '� ) -^^ U !G,`! F at receipt? By: Tested:
CC City: �-7— G',1044' 7
C Reported , Date/Time
u) State. Y>r4 S I Zip: 71 "'I ! I III — I I I I 2C
By: Reported:
Phone#: :t 5— Fax#. - '9SrS/_ Report Approval
Sampler Name: l•1 _ SF� Signature: q f6. by /�� y't'G �"
Ae { C ! s< k',L'',-
Approving Terry
❑ Bacon Date of IC.I7� 9 Z 3 ffi'I °L�3
Sampler Contact#: t'^ ❑ Owner ❑ Operator ❑Omer Technical Diane Nancy Approval: L? 3 .it L
System Type O Water Source: (J) Director: ❑ Turnage
y$#em T ¢: ❑ Hardin
Public i Private Bottled/Vended !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
Sample Identification Collected Sample Type: O; Free Please Test Method: SM9223 Sample
Include Lab ID of ❑ Resubmit*
Use Specific Address/Location Descnption Date Time g mg/L Colilert-18 Presence-Absence Format ID
DO NOT USE SITE# ' Previous Positive
t m c� Please circle N 3 0. '4 r on All Samples I] Total Rejection Total Coliform E.Coil Number
Raw Wells Use Source ID for Well Sampled;Ex.G1234567A ° } AM or PM �? o tt r Related to the mg/L Criteria#
P `� (§-
I Original Sample 9 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:3/2012 Rejection Criteria#Definitions 2) Quantity insufficient for analysis(120mL required) 4) Heavy SiltlTurbidity Present 6) Other: