Northlake 635(4)-LR010109 (3) ~ARRANT COUNTY PUBLIC HEAL TH LABO. /ORY
1800 University Dr., Ft. Worth, TX 76107
WATER BACTERIOLOGY Lab Bio. 48010 (817)8714245
Date and Time Ro~c'd'~ ' ' ~ ' ' 4: ! ,.'~ DateR~)e~d., · r, c '~
Sample No. . ,.~ ..: ', ? &*~ ,, ~ ::.
Do Blot Mark Above This Line *----Please Print Below with BALLPOINT PEN OR TYPEWRITER:
,/t NAME OF WATER SYSTEM
POIBIT OF gOLLEffTIONISAMPLE DESCRI~TIOBI
SEND
RESULTS
TO:
NAME
/q-':"? I':'~'~ t~"~~
STRETT ADDRESS (P.O. Bo,x)
CITY
PHONE ~ ///.~' ,~/b~,~ L./~..~(.~ COUNTY
~me of
Collection Month Day Year TIME
TYPE OF SYSTEM SAMPLE IS
~ Public ~ Dai~ ~ Dist~i~ ~ Raw
~ I~ivJdual ~ Bottl~ ~ Constr~tion ~ R~eat
~Sc~l ~V~d~ ~ G~collSweetlChill Water
~Other
TX'
IIq
AMIPM
Water System I.D. No.
(Zip Code)
I, 171 1
Collected By
WATER S ~fl~CE
[]River ~]Lake
[]Well
Well Depth
Chlorine Residual
Additional Information:
LABORATORY REPORT (Do no write below) TECH
MMO-MUG
Prosence/Absence
Coliform Organisms
FoOt Found
und
[] Total Coliform group
[] ~$cherichia co/i
[] Repeat samples required
[] Unsuitable -- See bebw
Membrane Filtration {MF)
Coliform Organisms
[] Not Found
[] Found
Total ColiformllO0 mi
E. co///lO0 mi
Fecal ColiformsllO0 mi
[] Unsuitable -- See below
MMO.MUG
Most Probable Number (MPN)
Coliform Organisms
[] Not Found
[] Found
Total
Coliform: MPN/IOOml
E. col~' MPNIIOOml
[] Unsuitable -- See below
UNSUITABLE FOR ANALYSIS-PLEASE RESUBMIT
[] Sample too old. Sample net received
within 30 hours of collection
[] Date discrepancy or form incomplete
(See encircled item)
[] Leaked in transit
[] Ouantity too great to permit agitation
[] Excessive chlorine residual: mglL
[] Ouantity insufficient for analysis
(100 mi. required)
[] Heavy (silt/bacterial growthJ present,
possibly compromising test results
[] Sample received on Friday
[] Other
~
H-220 GPC-2190 REV. 6-97