Cambridge Phase 2-LR 970205 (3)Date and T'l~te"Rec~:~--~ '"~ . - Date '
sample No
W~er System I.D, No.
TO: I ~m/]~ll II II i i i il Tx
~ ~'-~. ~_CI~ ZIP C~
Det : . .... col:
~lle~ion ~ D
T~PE OF SYS.]'EM SAMPLE IS W~TER ~URCE .... :
(Public Systems Only)
[~ublic~ ~' ~4' 'D DiStflbutibh [] Raw [~er E~I'al~''~ ':~
~ I n~m ~ 1 [~stru~iII~s~] Repeat ~..Wll~l**~;:~Well Depth
[] Special Chlorine Residual
[] School
Ownership or other information:
? t. ':' Water of Satisfactol~,~-quality must be free frOm Coliform'organismS
" _ Coliform Organisms *'~_~No~ Found
[] FOUnd
[] Total coliform group -...
[] Repeat samples required
?-] Unsuitable--.See below
[] Sample too old. Sample not received [] Quantity insufficient for analysis
within 30 hours of collection (lO0.ml. required)
[] Date discrepancy or form ineomplete [] Heavy (silt/bactmi~ growth) present,
possibly compromising test results
(See encircled item)
F'I Leaked in fransit~ ::[~.~