Cambridge Phase 2-LR 970205 (2) W~,,'rER BACTERIOLOGY T,~x~s Department of Health
Fo~frl~,o.: G~-19 (Pf,'~O3) ( .~u of Laboratories
Date ~nme Re~u./ _ Date
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Water System I.D.N.o. ~" ~= . __ NA.I~E ~)F WATER SYSTE~-'- r
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NAME
RESULTS /~lol~lol~l 1~11{1~5i
STREET ADDRESS [P.O. Box)
TO: _,lg~JtJJ'l~SJ I I I I I I I I I I Tx 715'1 I I ?H Ol ~'
crr'Y zip CODE
Time of ,_,,..,.=,
Collection '
MONTH AM/PM OOLLECTED BY
TYP~OF SYSTEM SAMPJ.E IS
(public Systems Only) WATER ~OURCE
~ublic [] Dairy [] Distribution [] Raw [] River [] Lake
[] Individual [] Bottled [~mstmction [] Repeat [] Wetf Well Depth
[] Special Chlodne Residual
[] School
Ownership or other information:
:~ ' Water of ~da~ ~1~ ~'~ must ~ ff~ from C~m o~isms
Colifo~ O~is~ ~N6t Fou~
~ Found
[] Total coliform group
[] Repeat samples required
4~] Unsuitable-- See below
UNSUITABLE FOR ANALYSIS = PLEASE RE~I~IT
[] Sample too old. Sample not received [] Quantity insufficient'for analysis
within 30 hours of collection (100'ml, required)
Heavy (silt/bacled~_. growth) present,
[] Date discrepancy or form incomplete [] possibly compromising test results
(See encircled item)
[] OtherLeaked in transited.. " ~~ ::