Northlake 635(4)-LR010109 (5) /--TARflANT COUNTY PUBLIC HEALTH
O A'#.~.i.r i.),~,k .f~ ~.~ 1800 University Dr., Ft. Worth, TX 76107
WATER
Lab No. 4801,0., (817)871-7245
Oateand~me~Kd.. ~': "-'~ '!~' ' Date
Sample No'.' ~' '/ ..... ' ''
Reported
SEND
RESULTS
TO:
Do Not Mark Above This Line -----Please Print Belew with BALLPOINT PEN OR TYPEWRITER:
/~f: NAME OF WATER SYSTEM
Prom OF COt c. oms . t
NAME
STRE~ ADORESS IP.O. Bex)
CI~ (Zip :ed9}
PHONE ~ COUN~
Water System I.D. No.
"'""" I lPl q
Time of
Collection Month Day Year TIME AM/PM Collected By
TYPE OF SYSTEM SAMPLE IS WATEI~OURCE
~1~ Public [] Dairy [] Distribution [] Raw [] River '~'-FrlLake
I--]individual []Bottled "'"~ Construction []Repeat I--1 Well
[]School []Vended ~--161ycolISweetIChill Water Well Depth
[] Other Chlorine Residual
Additional Information:
LABORATORY REPORT ldo no write below) TECH
MMO-MUG
PresencelAbsence
Coliform Organisnm
FoOt Found
end
[] Total Coliform group
[] E$~herichia coli
[] Repeat samples required
[] Unsuitable -- See below
Membrane Filtration (MF)
Coliform Organisms
[] Not Found
[] Found
Total Coliform/100 mi
~coli/ l O0 mi
Fecal ColiformsllO0 mi
[] Unsuitable -- See below
MMO-MUG
Most Probable Number (MPN)
Celiferm Organisms
[] Not Found
[] Found
Total
Coliform: MPNIIOOml
E. co/E MPNI100ml
[] Unsuitable -- See below
UNSUITABLE FOR ANALYSIS-PLEASE RESUBMIT
[] Sample too old. Sample not received
within 30 hours of collection
r-l' Date discrepancy or form incomplete
(See encircled item)
[] Leaked in transit
[] Ouantity too great to permit agitation
[] Excessive chlorine residual: mglL
[] Quantity insufficient for analysis
(100 mi. required)
[] Heavy (silt/bacterial growth) present,
possibly compromising test results
[] Sample received on Friday
[] Other
H-220 GPC-2190 REV. 6-97