Reserve-LR000106 TARRANT COUNTY PUBLIC HEALTH LABORATORY
1800 University Dr., Ft. Worth. TX 76107
WATER BACTERIOLOGY Lab .o. 480t0 18tTm71-7245
Date and Time Rec'd,', ' ';- : ~, Date
Sample No. -'~ - '.: ~.~ ? 'l~ee5rldd' -
On Net Mark Ahnve This Line ---Pleasu Print Below with 6ALLPDINT PEN DR TYpEWRI~'E~:
NAME OF WATER SYSTEM
POINT OF COLLECTION/SAMPLE DESCRIPTION Water System I.D.
NAME
RESULTS STREET ADDRESS (P.O. Box)
_ ./ .~ ~. ~' ~
TO: ... Tx /
~, C1~;7 ? (Zip Code,
PHONE ~ COUN~
Collection Month Day Year TIME AM/PM Collected By
TYPE OF SYSTEM SAMPLE IS WATER SOURCE
I~rPublic r'"JDaky [-IDistribufion r"lRaw E:]River [--ILake
[--hndividual r-]Bottled [~Cbnstruction [--IRepeat I-]Well
r-ISchool [-1Vended r-IGIycol/Sweet/Chill Water Well Depth
[] Other Chlorine Residual
Additional Information:
LABORATORY REPORT (Do no write below) TECH
MMO-MUG Membrane Filtration {MF} MMO-MUG
PresencetAbsence Most Probable Number (MPN)
Coliform Organisms Coliform Organisms Coliform Organisms
Not Found ~,~, Not Found Not Found
Found [] Found [] Found
[] Total Coliform group ~Total Coliform/100 mi Total
[] Esche~/ch/a co/i E. co/i/ lO0 mi Coliform: MPNIIOOml
[] Repeat samples required Fecal ColiformsllO0 mi E. co/~- MPN/IOOml
[] Unsuitable -- See below [] Unsuitable -- See below [] Unsuitable -- See below
UNSUITABLE FOR ANALYSIS-PLEASE RESUBMIT
[] Sample too old. Sample not received [] Quantity insufficient for analysis
within 30 hours of collection {100 mi. required)
[] Date discrepancy or form incomplete [] Heavy (silt/bactm'ial growth) present,
(See encircled item) possibly compromising test results
[] Leaked in transit [] Sample received on Friday
[] Quantity too great to permit agitation [] Other
[] Excessive chlor'me residual: mg/L
H-220 GPC-2190 REV. 6-97
TARRANT COUNTY PUBLIC HEALTH LABORATORY
1800 University Dr., Ft. Worth, TX 76107
WATER BACTERIOLOGY Lab mo. 480t0 ~8~7~87~.7245
Date and Time R'ec'd', Date
Sample No. ~" .... ' ~' ~ { .....
Do Not Mark Above This Line -----Please Print Below with BALLPOINT PEN OR TYPEWRITER:
NAME OF WATER SYSTEM
POINT OF COLLECTIONISAMPLE DESCRIPTION Water System I.D. No.
NAME
RESULTS STREET ADDRESS (P.O. Box)
To:
CITY (Zip Code)
~7~-I~
PHONE ~ COUN~
i I I' 1
Collec~on ~onth Day Year TIME AM/PM Collated By
TYPE OF SYSTEM SAMPLE IS WA~ER SOURCE
~ublic DOairy ~Distribution DRaw DRiver BLake
~lndividual ~Bottled ~truction ~Repeat ~Well
~School ~Vended ~ Glycol~SweetlChill Water Well Depth
Addhional Information:
LABORATORY REPORT (Do ne write belo~ TECH
MMO-MUG Membrane Filtration (MF) MMO-MUG
PresenceJAbsence Most Probable Number (MPN)
Coliform Organis~ Coliform Organisms Celifo~ Organics
~ Not F~nd ~'
~ Found
~ Total Coliform gr~ Total Coliform/lO0 mi Total
~ E$c~hia co/i ~.~o/~100 mi Coliform: MPN/IOOml
~ R~eat sa~ required F~al Col/forms/lO0 mi E. co/L' ~MPN/IOOml
~ Unsuitable -- ~e below ~ Unsuitable -- See below ~ Unsuitable -- See below
UNSUITABLE FOR ANALYSIS-PLEASE RESUBMIT
~ Sadie too old. Sa~le not r~eived ~ Ouantity insufficient for analysis
~thin 30 hours of collection (I00 mi. requiredl
~ Date discrepancy or form incomplete ~ Heavy (silt/bacterial growth) present,
(~e encircled item) possibly compromising test results
~ Leaked in transit ~ Sample received ~ Friday
~ Ouantity too great to pm~t agitation ~ Other
~ Excessive chlorine residual: mglL