Cambridge Phase 1-LR 940921 (3)WATER BACTERIOLgGY Texas Department of Health
Form No. G-19 (Rev.: ) BurfA,f Laboratories
Date and Time Rec'd. Date 9f~
Sample No. ~ISEi~' :~'-e~ ~!4163J Reported
De not mark above ti/is line,..-~Plea.~e print with balll~int pan er typewriter
Water System I.D. No. NAME OF WATER SYSTEM
NAME
STREET ADDRESS (P.O. Bdx}
· o: ,,,.., I,,, I
CITY ZIP CODE
Date and
ColLection
MONTH DAY YEAR TIME AM/PM COLLECTED BY
SAMPLE IS WATER SOURCE
TYPE OF SYSTEM (Public Systems Only}
~,ublic [] Dairy [] Distribution [] Raw [] River '~Lake
[] Individual [] Bottled ~Construction [] Repeat [] Well Well Depth
[] School [] Special Chlorine Residual/, ,~'
Ownership or other information:
LABORATORY REPORT (Do not write below)
Water of satisfactory ba_cteriological quality must be free from Coliform organisms
Coliform Organisms .~-Not Found
[] Found
[] Total coliform group
-, [] Escherichia coil
...... [] Repeat ~mples required
[] Unsuitable -- See below '~. ' ' .... ..-:-.
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