DR1201-LR130816 (2) \^
DRINKING WATER (P/A) COLIFORM SUBMISSION/REPORT FORM ..-,;• .°1-77‘.i:'• Tarrant County Public Health Test results
•t•- ; _ , .' •_ North Texas Regional Laboratory meet all
, . ?-• requirements a ..--r
Please corn•lete all a.•licable info, ....n re.tte. _•,• F°E' - - *e form. t 1101 South Main Street,Suite 1700 r
9 �\}f >; of NELAP
Public PWS ID#: E` Elf&,: Fort Worth,TX 76104 unless stated
,T•/
(Must be 7 digits;include all zeros) Phone (817)321.4778 otherwise.
Water * *, Fax(817)321-5378 NELAP Certificate#:
Systems PWS Name: e){ TCEQ Lab ID:48010/USEPA Lab ID:01471 T104704339-12-4
Only: County: \` 5 ;; LABORATORY USE ONLY-DO NOT MARK TO THE RIGHT OF THE BOLD CENTER LINE
Sample Iced?
Received Date/Time
Yes No B Received: AUG 14'13 8
o Name: Y
0 J
Address: J t I t 4{- y ),f n ; If no,temperature Tested Date/Time
CO ! 7 V Y at receipt? By: Tested:
N
C4 City: r+
C - r-+t — o Reported Date l Time
tj r State : ' x 1 Zip: 7 1 4 1 1 1 1 1 1 1 - 1 I I I C By. Reported:
17 " 7 7� �-7 7 :3) 1 ) ! P pp ' / t
Phone#: „> 3W Fax#: s/ Q Report Approval /n r;.:YlI15-1.-'f C 1Signature: ! ' .
Sampler Name: �` '�
Yi f
N('M ` Ac.; ,:!n %' Terry Marc
Sampler Contact#: ci 1" 7 1 4 ? ❑ Owner ❑ Operator
Approving ❑ Bacon ❑ Lewis Date of
p ❑Other: Technical
f' Diane Nancy Approval:
Manager: ❑ Hardin ❑ Turnage
Circle Appropriate System Type: Please Circle Ap ropriate Water Source: ge
Groundwater urface Water Groundwater with Chlorine Lab Results
Public , Private BottledNended Unsuitable
(Well) (Lake,river) Surface Water Influence Residual Sample- Note:All test results relate only to the samples as received. Laboratory
Sample Identification Collected Please
Sample Type: (J) PWS only: Free Test Method: SM9223 Sample
Include Lab ID of mg/L Resubmit" Colilert-18 Presence-Absence Format ID
_
Use a specific address,location,or description Date Time o _ — 9
io io Previous Positive
For PWS samples,do not use site#only,include a 8 Total Coliform E.coli Number
ca N Please circle 7, 3 a on All Samples Total Rejection
address;for PWS raw wells,use Source ID#; Ex. ce Related to the
G1234567A (� 0 '' AMoorrPM O v Original Sample j �mmg/L Criteria# Present Absent Present Absent •
5�0 (ttekYtt°w iLG /7 ��O Pm ❑ g ❑ ❑ ❑ •� �/❑ 0 ❑ ' t-t t ie_j=j r
Vki'llot y` pm ❑ ❑ ❑ ❑ ❑ I 10 L I 0 0 0
am JJ��e pm 1=101111=10 f 0 0 0 0
r �\n\SG d pm ❑ ❑ ❑ ❑ ❑am
2 rtsn
o \� pm ❑ ❑ ❑ ❑ ❑ Y", 0 0 0 0
\ am
pm ❑ ❑ ❑ ❑ ❑ r 0 0 0 0
am
pm ❑ ❑ ❑ ❑ ❑ r 0 0 0 0
am
164r1.1CV.0lr‘ T!5 JC pm ❑ El ❑ ❑ ❑ r 0 0 0 0
am
1 i7Lt L., pm ❑ ❑ ❑ ❑ ❑ t
Coliform P/A `Unsuitable Sample Analysis- 1) Sample Too old. Not received within 24 hours of collection 3) Excessive Chlorine Residual(>10 mg/L) 5) Form Incomplete/Date Discrepancy(Errors Circled)
Form: 1/2013 Rejection Criteria#Definitions 2) Quantity insufficient for analysis(120mL required) 4) Indeterminate Result 6) Other: