Cambridge Phase 1-LR 940921 (2)WATER BACTERIOL,~'%Y Tex~s. Pepartment of Health
Form No. G-19 (Rev.'. .1 Bu[ ?f Laboratories
_ ,./?¥
Date and Time Rec'~.~..?n ,-,
Sample No. ' ........ Repo.ed
- po net ~ ~ove ~is 1~ Pl~e ~t wffh ~int pe~ or ~p~rit6r.
.' I I I I I I I ~:i-.~l~lZlq i~/I;'tyt I~}~:1~1 I~l/~lr~-k~l'l I
Water System I.D. No. NAME OF WATER SYSTEM
POINT OF COLLEC~N COUN~
NAME
ziP CODE
Date and '
'lqmeo, bl~[ ~. ~._L..~ ~=l-~ ~
Collection
MONTH DAY YEAR TIME AM/PM COLLECTED BY
SAMPLE IS WATER SOURCE
TYPE OF SYSTEM (Public Systems Only)
~.Public [] Dairy [] Distribution [] Raw [] River [~'Lake
[] Individual [] Bottled [] Construction [] Repeat [] Well Well Depth
[] School [] Special Chlorine Residual /..~/'x:'" ....r?_-
Ownership or other information:
LABORATORY REPORT (Do not write below)
Water of satisfactory bacterielogical quality must be free from Coliform organisms
Coliform Organisms ~ Not Found
[] Found
[] Total coliform group
[] Escherichia coli
r~ .~.~.l~.Repeat1~,,l~es. requ~ed_ ., '; : .~
[] Unsuitable -- See below .:
NENTC?; --:'~-..-- :' :2"::"'-" -"?.. ? -' ? '-' · !;~::l' :;~
L~..,._'._~,o ,:.' -.-- .- ~: .... :.;;..__
UNSUITABLE FOR ANALYSIS - PLEASE RESUBMIT
[] Sample too old. Sample not received [] Quantity insufficient for analysis
within 30 hours of collection (100 mi. required)
[] Date discrepancy or form incomplete [] Heavy (silt/bacterial growth) present,
(See encircled item) possibly compromising test results
[]Other ..~.~.~ ~E