Stratford Manor-LR 990617CITY OF LEWISVp:LE LABORATORY - WATER BACTEmOL~Y
Point of Colleclion Collected By Date
(Mo/Day/Yr) --
Address: STREET
Waler Syslem Idenlificalion Number
TYPE ~P~ [] Individuai
SYSTEM: [] Other
SAMPLE [] Distribution [] Special E~Conslruction
IS: [] Repeat for sample # ~
[] Recheck for sample #
WATER [] FINer [] L~,ke [] Well "~
SOURCE:
Well depth Chlorine Residual
M.P.N. Total Coliform /100ML
(Colilert) E. Coti.
Membrane Filter/Fecal Coliform: 1st Dil. __/ mi 2nd /__mi ~
Avg.__ ; mi
Unsuitable For Analysis: .--..
[] Form Income (see encircled ilern)
[] Sample Ioo old, nol received within 30 hours of collection ~
Excessive chlorine present in sample
[] Unsuitable container
[] Heavy, non coliform bacleria/silt present, possibly obscuring and compromising lest
[] Quantity leo great Io permil agitation
[] Quantily insufficient for analysis (100 mi minmum)
Analyzed by · I
Wat~' of satislaCtOl'y bli~rological quality iI,~uld b~