Cambridge Phase 2-LR 970205 (4)F~m'~o. 1~-19 (R~/'"~93) I~..,~ Of Lal:~_.ratorieS
Date ~md Time"Rec~:~... .... ....~ ' Date ,
Water Sy~em I,D, No, ~ ,. , _~AME OF WATER SYSTEM
Subm~erI.D. No. I'1 t I FI I II
NAME ,,.,
STRE~ ADDRESS (P.O. ~x)
ITx I
CI~ ZIP CODE
Coll~ion c~aY
~N~ DAY ~AR TI~
~PE~F SY~EM SAMPLE IS
(Pu~ Sy~ ~y) WATER ~URCE
~Mic ~ D~ ~ DiaH~on ~ Raw ~ River ~ L~e
D~nai~dua ~ ~~n DR~=t ~W~, W~,~
~ ~hool ~ ~ed~ .~. ' Ch~dne R~idu~
~_... -
O~emhip or o~er informa~on:
Water ofsa~sf~ ~i~ ~' m~ be E~ EOm ~li~m 0rg~ms...
~ Found '
~ Re,at samples r~uE~
UNSUITABLE FOR ANALYSmS- P~E RES~
~ Sa~me t~ old. Sarape not r~iv~ ~ Ou~ ~ns~d~m for ~a~s
~in 30 houm of ~lm~ion (100 mm, r~ir~) "~:
[] Date discrepancy or form incomplete [] Heavy (siltJbacteri~growth) present,
(See encircled item) ~ possibly compromising test results
[-~ Other C~
Leaked in tran~ /' ~