Gateway BP(1.2)-LR 970123 (2)CITY OF LEWIS..~-LE LABORATc
WATER BACTF_.,.,OLOC-,Y
/ Name of ~'~'er System County
Point of Colleclion Collected By Ti~
(Mo/Day/Yr)
Repo.ing STREE~I~
Water System Identification Number
[] Individual
TYPE [] Public
OF
SYSTEM: [] Other
[] Distribution [] Special
[] Repeat for sample #
[] Recheck for sample #
[] Other
/~ Construction
SAMPLE
IS:
WATER [] River dLake [] Well
SOURCE: Well depth Chlorine Residual
ANALYTICAL METHOD &
RESULTS:
P~entJAbsent: Total Coliform~ Present
Fecal Uomorm Present
M.P.N. Total Coliform
Fecal Coliform '__
/IOOML
/100ML
mi '~nd
/ mi
Membrane Filter/Fecal Coliform: 1st Dil. /
Avg. /_ mi
Unsuitable For Analysis: ~
[] Form Incomplete (see encircled item) ~
[] Sample Ioo old, not received within 30 hours of collection
[] Excessive chlodne present in sample
[] Unsullable container
[] Heavy, non coliform bacteria/silt present, possibly obscuring and compromising lest results
[] Quantity too great to permil agitation
[] Quantity insufficient for analysis (100 rnl minmum)
[] Other
Analyzed by % · '~ '
Water of satisfactory ba~srological quality sh~A~/d be free from Coliform Organisms.