Gibbs Station 2-LR 930907[~WATER BACTERI~I~'~Y "..- ' Tex~epartment of Heath
Form No. ~i-19 (Rev. J) - Bur )f Laboratories
Date and '13me Rec'd. ' ...... Date
. ·.: - .- . ~. Do not mink ~'lhis line -- Please print with ~Jlpoint pen or typewriter.
Water System I.D. No. NAME OF WATER SYSTEM
.O .T OF CO,,EC O. COU.
NA~E
STREET ADDRESS (P.O. Box}
~[,f~, CITY ZIP CODE
Date and
CollectiOn
UON'rH D~Y ...YF-~ T~E ~VW'M COU.ECTED SY
~~ SAMPLE I~
TYI3E OF SY~'I'E~ ' · ~ ~.....-,,j~. (Public Systems Only) WATER SOURCE
~rublic [] Dairy ~/...j ~-t~ibution [] Raw [] River [] Lake
[] Individual [] Bottled {~,~onstruction [] Repeat [] Well Well Depth
[] School [] Special Chlodne Residual
Ownership or other information:
LABORATORY REPORT (Do not write below)
Water of satisfactqry bacteriological quaJjty must be free from Coliform organisms
Coliform Organisms ~ot Found
- [] Found
[] Total coliform group
[] Escherichia coli
[] Repeat samples 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
[] Leaked in transit
[] Other
Form No. G-19 (Rev.'-,~'93)(._,,.,r Burea~ of Laboratories
Date and Time Rec'd .... Date
Sample No. . .. ,.Reported
C'-..l ? G Do not mark aJ:x:~Od~l~ ~ti~*----P~as~' prlnt,aldtl~t pel~ or typewriter.
I
Water System I.D. No. NAME OF WATER SYSTEM
POINT OF COLLECTION ' COUNTY
Submitter .D. No. IIIIIII
NAME .
STREET ADDRESS (P.O. Box)
CITY .- ZIP CODE
........... ~3~ie andCollection Time °f ~L'NI~---JNTH''- D~RY- '~: '? :[--~-~ "~ ~--~-- ~ ......... C
SAMPLE IS WATER SOURCE
, TYPE OF SYSTEM (Public Systems Only)
[~ublic [] Dairy [] Distribution [] Raw [] River [] Lake
[] Individual [] Bottled [~C~onstruction [] Repeat [] Well Well Depth
[] School [] Special Chlorine Residual
Ownership or other information:
LABORATOR~ REPORT (Do not write below)
~Vater_ of satisfactor~ ~__~_,.eriological ~l~ality muatbe free from Coliform
organisms
: Coliform Organisms ~lot Found/,~_~
~- []Found ~ '
[] Total coliform group
. [] Escherichia_~ ,~ "'
' [] Repeat ~albplesr required
[] Unsuitable ~ See below
UNSUITABLE FOR ANALYSIS - PLEASE RESUBMIT
[] Sample too old. Sample not received [] Quantity insufficient for analysis
within 30 houm of collection (100 mi. required)
.'~[] Date discrepancy or form incomplete [] Heavy (siltJbacteriai growth) present, ~
: (See encircled item) possibly compromising test results
[] Leaked in ~'ansit
[] Other' '"
:
YYAT[~R Y T epanment of Health
: Date and ~m~'~ ~.'.-' .. : .......... Date ~ __ ~.
Sample No.---- ' ..... _.. ~
~ not m~ ~}i~ Pl~e ~~int pen or ~er.
Wamr System I.D. No. ~E
POINT OF ~LLECT~N
I I
Su~mm~r~.D.~o. I I I1 I I I
I,
NAME
~/ ~ S~ ADDRESS (P.O. ~x)
........ ~at, ~d ........ - ' -~ - ............
meof
~lle~ion ~ DAY Y~n ~ ~M ~C~D BY
(Public Sy~e~ ~ly) WATER SOUR~
~ubl~ ~ D~ ~ DistHbu~on
~ Indivi~al ~ Boffi~ ~ons~on ~ R~at ~ Well Well
Dep~
~ ~h~l ~ Spe~ Chlorine Residu~
~nership or o~er i~orma0on:
~BO~TORY REPORT (Do n~ wr~e ~)
. CoHf~ ~an~ ~ot Fou~~
/ ~ ~und
~ To~ ~l~orm group
~ Es~edchia ~li
' ' - DRem~~,qui~ :. ........
~ UnsuA~le ~ S~ ~1~
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 i~n t~ansit
[] Other
W A TEa ~B~C'~I~'~ ~.I~'''' Y T~ ~)epartment of Heath
Form No. G-19 (Rev.';~93) . . ~. : . Bui'eab of Laboratories
Date and Time Rec'd~ ~/",' '.'. ~...' '' ' : Date . O ~ -- ~'~ ~
Sample No. -'~ ~ ~ , ,-, ,- ~ Reported f' ! ~'"'
~ !;. ~'~ O,, Donotmark~.~.ll~is'line--Pl~b~ep~lnt~13a~l~ntpe~ortypewriter.
Water System I.D. No. NAME OF WATER ~YSTEM
: " POINT OF COLLECTION· COUNTY
SubmitterLD. No. I I I-'l'l I I I I ....
NAME .?,
STREET AD,DRESS (P.O. Box)
TO:
CITY ZIP CODE
....... and ": ' '
Collection '
MONTH DAY . . TIME AM/PM COLLECTED BY
· ":' TYPE OF sY~r-/~ (Public Systems Oebt) WATER SOURCE '
~"Public [] Dairy [] Distribution [] Raw [] River [] Lake
..~
[] Indhtidual [] Bottled mtm~on [] Float [] Well Well Depth
[] SchWa. . [] Special Chlorine Residual 'i
Ownership3 ~r oth~=e~information:
LABORATORY REPORT (Do net write below) ..~
Water of safisfactory~eriological qua~ty must be free from Coliform organisms
Coliferm Ol'ganl~ms ~lot Found ~ ' .
~ [] Found ~
[] Total coliform group
[] Escherichia coli
[] Unsuitable -- See below
-I
UNSUrr^ LE FOR ^NALys s- .Esu M T
[~] Sample too old. Sample not received [] Quantity insufficient for analysis
within 30 hours of collection (100 mi. required)
'~'[--I Date discrepancy or form incomplete [] Heavy (silt/bacterial growth) present,
(See encircled item) possibly compromising test results
[] Leaked in transit
[] Other
-
~O~~) .... : -. . ~f. L~mtode~
Date ~d
Water Sy~m I.D. No. NAME OF WATE~Y~TEM
~1~ OF CO~ECTION '
Submi~er I.D. No.
NAME
STRE~ ADDRESS (P.O. ~x)
C~ - ZIP C~E
i
'" Date'and ......... ' ...... I ~)/'~ '
I.,,i'/F I
Collection -
MONTH DAY YEAR TIME AM/PM COLLECTED BY
SAMPLE IS
~. TYPE O~F SYSTEM (Public Systems Only) WATER SOURCE
[~Public I--I'~ [] Distribution [] Raw [] River [] Lake
/
[] Individual [] Bottled onstruction [] Repeat [] .Well . Well Depth
[] School [] Special Chlorine Residual
Ownership or other information:
LABORATORY REPORT (Do not write below)
Water of satisfact~L~.ctedological qu~/, mu~J3e free from Coliform organisms
' Coliform Organisms /~l~l'6t Found/~
[] Found
[] Total coliform group
[] Esche#chia
'. i-1Repea~pl~'~eq~ired :-."
[] 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
[] Leaked in transit
[] Other