Gateway BP(1.2)-LR 960826 TARRAN~'COI~I'~Y PUBLI~ HEALTH LA~ORATO,,q[,
~"I~)LoG,~ 1800 Univers/ ,Ft. Worth, TX 76107
WATER BAC, ~R ,..... : : Lab190. 48010 ~817)871-724§
Date and Time Rec'd
~.) i "D~N~k Above This Line -----Please Print Below With BALLPOINT PEN OR TYPEWRI~ER~
NAME OF W~TER SYSTE~
s[PJo
RESUL,T~
TO:
POINT OF COLLECTION
NAME
P.O.
STREET ADDRESS [P.O. Box)
CITY ~ ~
P~'ONE ~
Water System I.D. No.
I
(Zip Code)
COUNTY
Date.d ...~-Time of"~"' I~l~l~dl~l t~,¢1 I
Collection Month Da,~ Year TIME AM/PM '-Collected By
-~ TYPE OF SYSTEM SAMPLE I~ WATER SOURCE
~ Public ~Dairy ~ qistribution ~ ~Raw ~River ...... ~Lake
O In'iv/dual OB~e~ ~onstruction ORepea, DWell -'
~School ~Ve~ed ~ GlycollSweetlChill Water Well Depth
Oth~ '. Chlorine Residual
LABORATORY REPORT ion 'no write below!
Membrane Filtration (MJ:)
Coliform Organisms
[] Not Found
[] Found
Total CoiiformllO0 mi
~E. c0£~100 nd
'F, erJal Colif°rms/lO0 mi
TECH
Additional Information:
MMO-MUG
Most Probable Number (MPN)
Coliform Organisms
[] Not Found
Total
· Coliform~"` .,.. MPN~IOOmi
'-' ~.E.c~li:. ' .'MPNIIOOmt
MM0-MUG
Pre%encelAbsence
~.,Aabl~t m 'prga ,isms
i~l~ Not FoUnd
I!' [] Found~ '
[ [] ~otal Coliform group
~ ~ E~cheri~hb co~'
: ~ ~peat samples re, ired
~ Unsuitable --See below ~ ,~e-~,~w.'.' 'm ...... ~ '~~~
UNSUITABLE FO~AN~S--PLEASE RESUB~T . ' '"' ~' '-.~.:, '
~ Sample too old. Sample nol received_~ ... ~ Qu~tity insufficient for ~alysis
within 30 hours of collection
[] 0ate discrepancy or form incomplete
ISee encircled itemF
[] Leaked in tran_s~_
[] Quantity too great to:permit agitation
[] Excessive chlorine re~id_~ual: __ . mg/L
H-219 GPC-2190
. (100 mi. required)
[] "Hea~ siltlbacterial growth) present.
~ possibly compromising test resLdt's -
[] Sample received on Friday
[] Other