Northlake 635(4)-LR001107 T~ ~ANT COUNTY PUBLIC HEALTH LABORAT~"~Y
1800 Univers,., dr., Ft. Worth, TX 76107
WATER BACTERIOLOGY L,b No. 48010 {817)871.7245
/ ~pdtllE OF W~T~R SYST? ~, r~/2~
.,' ., P~OFCOLLE~ON~AMPLE DESCRIPTION
NAME
RESULTS STRE~ ADDRESS (P.O. Box) .~
T0: ..._ / /
Cl~
~)Oate and
~ Do Not Mark Above This Line -----Please Print Below with BALLPOINT PEN OR TYPEWRITER:
Water System I.D. No,
,.--~ j
· x
(Zip Code)
1,1:11 I
Time of
Collection Month Day
E OF SYSTEM
r-lDairy
[] Individual [] Bottled
I-'lSchool •Vended
Additional Information:
MMO-MUG
Pr~SencelAbsence
F 0rganisms
ound
,l'~ Found ~ :.
'~ [] Total Coliform g~oup
r-~'~$c~erichia coli
r'-I Repeat samples required
[] Unst~itable -- See below
Year TIME AM/PM Collected By
SAMPLE IS WATER SOURCE
[] Distribution [] Raw [] River ~
~s~ruction [~q:)~at []Well
[] Glycol/Sweet/Chill Water Well Depth
[] Other Chlorine Residual
MMO-MUG
Most Probable Number (MPN)
Coliform Organisms
[] Not Found
[] Found
Total ' r
Coliform: MPNIIOOml
E. col~' MPNI100ml
[] Unsuitable -- See below
LABORATORY REPORT ldo no write betow)~
Membrane Filtration (&IF)
Coliform Organisms
[] Not Found
,[] Found
Total CoflformllO0 nd
Lc. co/i/1 O0 mi
Fecal ColiformstlO0 mi
[] Unsuitable -- See below
UNSUITABLE FOR ANALYSIS-PLEASE RESUBMIT
[] ~ . Sample not. received
[] Dare 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 nd. required)
[] Heavy (silt/bacterial growth) present,
possibly compromising test results
[] Sample received on Friday
[] Other
H-220 GI'C-2]90 Rl~V. 6-97
. ,. ,:..._)1RANT COUNTY PUBLIC HEALTH LABO~RY
~,"?~' 1800 Un~,,.~y Dr., Ft. Worth, TX 76107
WATER BACTERIOLOGY La. No. 48010 1817)871-7245
Do Not Mark Above This Line ..-..Please Print Below with BALLPOINT PEN OR TYPEWRITER:
NAME
RESULTS
STRE~ ADDRESS IP.O. Box)
PHONE #
Date and
Time of
Collection Month Day
TYPE OF SYSTEM
[~4~lic [--IOairy
[] Individual [] Bottled
r-ISchool []Vended
Additional Information:
(Zip Code)
COUNTY
Year TIME AM/PM Collected By
SAMPLE IS WATER SOURCE
str DiStribution i--]Raw DRiver
uction E~Rr~Peat [-1Well
r-]Glycol/Sweet/Chill Water Well Depth
r-]other Chlorine Residual
II
LABORATORY REPORT (Do no write below)
MMO-MUG
? P~sencelAbsence
orm Organisms
Not Found
Found ~
[] Total Coliform group
[] EsclmrkMa co/i
[] Repeat samples required
-- ~-..~-IELu"~ui'aue--See below
Membrane Filtration (MF)
Coliform Organisms
[] Not Found
E~_ Found
Total Coliforndl~O mi
E. co///lO0 mi
Fecal Coliforms/lO0 mi
[] Unsuitable -- Sea below
MMi
Most Probable Number (MPN)
Coliform Organisms
[] Not Found
[] Found
Total
Coliform: MPNilOOml
E. colL' MPN/IOOml
[] Unsuitable -- See below
UNSUITABLE FOR ANALYSIS-PLEASE RESUBMIT
[] Sample too old. Sample not received
within 30 hours of collection
[] Date discrepancy or form incompJete
(See encircled item)
[] Leaked in transit
[] Ouantity too great to permit agitation
[] Excessive chlorine residual: .moil
[] Quantity insufficimlt for analym
(100 mi. required}
[] Heavy (silt/bacterial growth) present,
possibly compromising test results
[] Sample received on Friday
[] Other
1]-220 GPC-2lg0
,~, RRANT COUNTY PUBLIC HEALTH LAB RY
-d~. ~--- 1800 U~sity Dr., Ft. Worth, TX 76107
WATER BACTERIOLOGY Lab No. 48010 (817)871-77.45
*~ a~d ~me Rec'd. Date
.~ De Not Mark Above This Line ----Please Print Below with'BALLPOINT PEN OR TYPEWRITER:
,- .¥,./ ~ME ~F ~R SYSTEM
~/~
' , P~ OFCOLLE~ONiSAMPLE DESCRIPTION
NAME
RESULTS
TO: ~TREET ADDRESS (P.O. Bo~/~- _ ~
Cl~
PHONE #
Water System I.D. No.
~ . .~ (Zip Code)
COUNTY
Date and
Time of
Collection Month Day Year TIME AMIPM Collected By
[~ubliPE OF SYSTEM SAMPLE IS WATER SOURCE
c [] Dairy [] Distribution [] Raw [] River I~]'L'~
[--hndividual []Bottled [~""~truction ~eat []Well
[]School [--IVended r-161ycollSweetIchili Water Well Depth
[] Other Chlorine Residual
Additional Information:
MMO-MUG
~-,~ I~sencelAbsence
Coliform Organisms
N
o~ound
Found
~. [] Total Coliform g~oup ·
E~]~.$c/~richi~ coli
[] Repeat samples required
r'~d~U~le -- See below
LABORATORY REPORT ldo no write below}
Membrane Filtration (MF)
Coliform Organisms
[] Not Found
[] Found
:. Total ¢oliformll~)O nd
£.co/i/100 mi
Fecal Coliforms1100 mi
[] Unsuitable -- See below
UNSUITABLE FOR ANALYSIS-PLEASE RESUBMIT
. ,Mo..Uo,,' ,, .
Most Probable Number (MPN)
Celiform Organisms
[] Not Feund
[] Found
'Total ' ~'
Coliform: MPNIIOOml
£.co1~' MPN!IOOml
[] Unsuitable -- See below
[] S~ tm) oh:l, Sample not received
Within 30 hours of collection
[~ Date discrepancy or form incomplete
[See encircled item)
[] Leaked in transit
[] Quantity too great to pm'mit agitation
[] Excessive chlorine residual: .mg/L
[] QuantLty insufficient fm analysis
(100 mi. required)
[] Heavy (silt/bacterial growth) present,
possibly compromising test results
[] Sample received on Friday
[] Othar
H-220 GPC-2190