Georgian Place-LR 990901 (2) ~./'~ ~eR_.ANT COUNTY PUBLIC HEALTH LABORA~,Y
I~ ~ ~' 1800 Univ~b~.../Or., Ft. Wo.", TX 76107
~ATE. BA~ERIOLOGY Lab No. ~010 (817)871-7245
Date and T~ Rec'd. Date
Sa~,e,0. ~ ~ ~,~ ~ ~ ~ .~ ,'
Do Not Mark [hove ~his Line -----Pte.. Print Below ~ ~PEN OR
I NAME OF WATER dY~TEM
POINT OF COLLECTIONtSAMPLE DESCRIPTI~ Wmr S~ I.D: No.
NAME
RESULTS STREET ADDRESS (P.O. Box)
To:
t/L PHONEt
COUMTY
Ib~te and -
Time of
Collection Manth Day
TYPE OF SYSTEM
17~Public [-]Dairy
r--hndividual [--I Bottled
[--ISchool r-lve~ded
IolSl I,-l lfl I Iz-l: I
Year TIME AM/PM
SAMPLE IS
I--]Distribution I-'lRaw
[~onstruction r-IRepeat
[] Glycol/SweetIChill Warm
[--[Other
Collected By
WATER SOURCE
f-lw~t
Weft Depth
Chlorine Residual
Additional Information:
MMO-MUG
Presence/Absence
Coliform Organisms
Not Found
~1~]Found
LABORATORY RE~
Membrane Filtration ~IF) ~ MMO-MUG
Meet Probable Number (MPN)
Coliform Organisms
[] Not Found
[] Found
Total ColiformllO0 mi:
E. co/~ 100 mi
Fecal ColiformsllO0 mi
[] Unsuitable -- See below
[] Total Coliform group
[] Esc/~ri~hia c~i
[] Repeat samples required
[] Unsuitable -- See below
UNSUITABLE FOR ANALYSIS-PLEASE RESUiMiT
Coliform Organisms
[] Not Found
[] Found
Total
Colifmm: MPNIIOOmt
£co/~ MPNIIOOml
[] Unsuitaide -- See below
[] Sample too old. Sample not received
within 30 hours of collectian
[] Date discrepancy or form incomplete
(See encircled item)
[] Leaked in transit
[] Ouantity too great to pm~mit agitation
[] Excessive chlorine residual: .mgtL
[] Ouantity insufficiem for analysis
(100 mi. required}
[] Heavy (silt/bacterial growth) present,
possibly compromising test results
[] Sampierecmed on Friday
[] or,~
H-220 GPC-2190
REV. 6-97
,,~ T~.QRANT COUNTY PUBLICi~'EALT LABORAT~Y
~ Wl~ '~ "~ ~ 1800 Unive, , Dr., F~ W~RI~;~TX 76107
, W,A:T:ER, BA~TE"IO L~GY
Date and ~ fle~ I ~- :
Do Not Mark Above
NAME OF W~
POINT OF C¢IONISAMPLE
RESULTS- ~E~ ADDRESS ~.0.
Tx
c,.
~PHONE ~
~of I~1 ~1 I--~
Colle~ion Moth O~ Yem TIME AM~PM ~l~d By
TYPE OF SYSTEM SAMPLE iS WATER SOURCE
[~Public I"'lDairy [:::]Distribution I"'lRaw r-IRiver ~
· r-'! Indi~,idual: r-]Bottled i~onstruction r-IRepeat I--]Weli
E:]School I'-IVended I~ Glycol/SweetlChill Water Well Depth
["~Other Chlorine Residual
hMo.,,uo .......
~~.b,l~ N~umber (. PN)
t
within 30 hours of collectian
[] Date discrepancy or form incomplete
(See encircled item}
[] Leaked in transit
[] Ouantity ton great to pmmit agitation
[] Excessive chlorine re,~lud: mgtL
E::] Heavy (silt/bactorial growth) present,
possibly compromising test results
[]. Sample received on Friday
H-220 GPC-2190 REV. 6-97