Cambridge Phase 1-LR 940921 (4) WATER BACTERIO' -qY Tax --nepartment of Health '
Form No. G-19 (Rev. $) But of Laboratories
Sample No. Re~ed
Do not m~ ~ove this line ~ Ple~e print with ball~int pen o ewriter.'
POINT OF COLLECTION COUN~
:?~'~L'~/ Submi,erl. D. No. ] ] ] ]
NAME
RESULTS
STRE~ ADDRESS (P.O. Bdx) '
Cl~ ZIP CODE
Date and
Collection
MONTH DAY TIME AIVI]PM COLLECTED BY
TYPE OF SYSTEM SAMPLE IS
(Public Systems Only) WATER SOURCE
[~,lPublic [] Dairy [] Distribution [] Raw [] River ~['Lake
[] Individual [] Bottled ~,Constmction [] Repeat [] Well Well Depth
[] School [] Special Chlodne Residual /, -,~9~ Ez-
Ownership or other information:
LABORATORY REPORT (Do not write below)
Water of satisfactory bacteriological,, quality must be free from Coliform organisms
Coliform
Organisms
[] Not Found
[] Found
[] Total coliform group
[] Escherichia coil
[] Repeat samples required
[] Unsuitable -- See below
DENTON MUNICIPAL LAlgORATOE¥
LAB. NUMBER
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
[] Leaked in transit