Gateway BP(1.3)-LR 990405 (4)~ITY (~F EEWlSVILLE LABORAT~Y' WATER BACTERIO£ Y
N~ o~ter ~yttem
of.Collection Collected By-- Date Tim
(Mo/Day/Yr)
Billing/
Reporting
Address:
NAME
STREET
c,TY TEx^s__ .
TELEPHONE(C~ ~ ~'~i t-' -~7_~ode)
Water System Identificatio~ Number
TYpF' , E~'ublic
OF ~ &her
SYSTEM:
[] Individual
SAMPLE
IS:
[] Distribution [] Special truction
[] Repeat for sample # /
[] Recheck for sample
[] Other
1100ML
/I~00ML
WATER [] River ~,Lake [] Well
SOIelRCE: Well depth/ Chlorine Residual
ANALYTICAL METHOD & RESULTS:
Present
Present
M.RN. Total Coliform
(Colilert) E. Coll.
Membrane Filter/Fecal Coliform: 1st Dil. /__
mi 2~d____/ mi
Avg / mi
Unsuitable For Analysis:
[] Form Incomplele (see encimled item)
[] Sample too old, not received within 30 hours of collection
[] Excessive chlorine present in sample
[] Unsuitable container
[] Heavy, non coliform bacteria/silt present, possibly obscuring and compromising test result.'
[] Quantity Ioo great Io permil agilation .
[] Q~uantity insufficte~! for analysis (100 mi minmum)
[] Other ~;;~
~*~ Analyzed by%~
W,l~ o! satisla~ ba¢,rological quality sh~d be f~ree from Coliform Organisms.