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TARRANT COUNTY PUBLIC HEALTH LABORATORY
1800 WATER BACTERIOLOGY Lab Non Dr., Ft. Worth, 48010 (817)871-7245
Date and Time
Sample No. 'L
Do Not Mark Above This Line Please Print Below with BALLPOINT PEN OR TYPEWRITER:
)7 O i CO PPS LL--
NAME OF WATER SYSTEM
7`; j -o vn t t�11; 6,
POINT OF'COLLECTIONISAMPLE DESCRIPTION Co I2 r
SEND
RESULTS
TO:
LtaRRy D F} 5
NAME
ASS PAR.K y RLV
STREET ADDRESS (P.0. Box)
Cr rPt tL T7( 7 ;n/ 9
CITY
PHONE
��e and
Timeof/
�ec�bn Month Day
,TYPE OF SYSTEM
ublic ❑Dairy
['Individual ❑Bottled
❑School ❑Vended
V ?y
AddtionalInformation: r
®t`n
..t
PresencelAbse
Coliform Organisms
Not Found
Found
Total Col
V
group
Esc h is co/i
eat samples required
nsuitable See below
Sample too old. Sample not received
within 30 hours of collection
Date discrepancy or form incomplete
(See encircled item)
Leaked in transit
Quantity too great to permit agitation
Excessive chlorine residual: moll
TIME
"'no ST cto2
COUNTY
SAMPLE IS
❑Distribution ❑Raw
[$Construction [f{lepeat
GlycolUSweetIChill Water
LABORATORY REPORT (Do no write below)
Membrane Filtration IMF)
r Pa
Reported
Coliform Organisms
Not Found
Found
Total Cokforml100 ml
E.co.W100 ml
Fecal CoSforms1100 ml
Unsuitable See below
UNSUITABLE FOR ANALYSIS– PLEASE RESUBMIT
P EP'p2es c C- T
Water System I.D. No.
P.O ROA 97P
(Zip Code)
l
AMIPM Collected By
WATER SOURCE
❑River ❑Lake
❑Well
Well Depth
['Other Chlorine Residual
D E .tAi -r2 FROM R LL
TECH
MMO -MUG
Most Probable Number (MPN)
Coliform Organisms
Not Found
Found
Total
Coliform: MPN1100m1
E.cc% MPNI100m1
Unsuitable See below
Quantity insufficient for analysis
(100 ml. required)
Heavy (sit/bacterial growth) present,
possibly compromising test results
Sample received on Friday
Other
11 GPC -2190 REV. 6-97