Gateway BP(1.2)-LR 960710WATER BAC'rERIOI. '-"Y
Form No. G-19 (Rev. L ,)
Te)c ~partment of Health
Bure,.. of Laboratories
Date and '~me Rec'd. Date
Sample No..~. Reported.~,, p'/~--,~'
Do not mark/~ 9v~e this line -- Ple~e print w~ ~ll~nt ~ O~'~; "~
Water System I.D. No. I NAME OF WAT~T~ ~ '~-' ~ ~
POINT OF COLLECTION COUN~
I
SubmiEerI.D. No. I I I I I It, I
STR~ ADD~ESS (P.O. ~x~ / ' '
TO:
Cl~ I · ZIP CODE
Data and ~
Collection -
MONTH DAY YEAR TIME AM/PM
'P(PE OF SYSTEM
SAMPLE
IS
· (Public Systems Only)
I~blic [] Dairy [] Distribution [] Raw
[] Individual [] Bottled [~nstzuCtion [] Repeat
[] School [] Special ~
COLLECTED BY
WATER SOURCE
[]River [~ake
[] Well Well Dep~.~.~
Chlorine Residual
Ownership or other information:
LABORATORY REPOI~T (Do not write below)
Water of satisfactory ba.cteriologicai quaJity must be free from Coliform organisms
· Coliform Organisms ~Not Found
'[] Found
[] Total coliform group
[] Escherichia coil
[] Repeat samples required
~ Unsuitable m See below
UNSUITABLE FOR ANALYSIS - PLEASE RESUBMIT
[] Sample too old. Sample not received
within 30 hours of collection
[] Date discrepancy or form incomplete
(See encircled item)
[] Leaked in transit
[] Other
[] Quantity insufficient'for analysis
(100 mi. required)
[] Heavy (silt/bacterial growth) present,
possibly compromising test results