Woodlands-LR 950807WATER BACTERIOLOGY T~$ I:)epm1~ent of~l ,e~dth
Form No. G~19(R~ ~93) _ ~ _ E ~u of Laboratolies,
Date and Time Rec'd.
rna~ above mis nne-- Please pdnt with 13d~t'l~n'~r ~w~lter.
NAME
STREET ADDRESS (P.O. Box)
'~ ZIP
Dateand
SAMPLE 18 WATER SOURGE
TYPE OF SYSTEM (Pubac Sysam~ onb/)
[~ublic [] Dairy [] Distn'butiort [] Raw [] River [] Lake
[] Individual [] Bottled [] ConstnJ~on [] Repeat [] Well Well Depth
i'll'SChOol .",. [] Specbd Chlorine Residual.,
~ or o~er information;
: . LABORATOfly ~1~ not write below)
[] Total ooli~orm group.
[] Repeatsamples required
[] Unsuitable-- See below
}~,
UNSUITABL'E FOR ANALYSIS - PLEASE RESUBMIT
[] Sampl~tO~ old. Sample not received
within 30 hours of collection
[] Date discrepancy or form incomplete
(See encirc{ed item)
[] ~Q~jn~l~fli~efli ior analysis
[] Heavy (silt/bacterial growth) present,
possibly compromising test results
WATER BACTE_RI~OGY
Date and 'nme Re~"~. Date
Submittm'l.D. No... i III !11
RF. SULT~ [~i~.~,T I]::~J'~i'gz~'~l~ IJT~,d'IFI~ I I I I I I I I I I I I i i J
__ ._//TYPE OF sY~r-r, ld
L..~Public [] Dairy
~ pAY. YE,VI TIME - ~ __~
[] Distribution [] Raw [] River I-] Lake
[] Construction [] Repeat [] Well Well Dep~
LABOnATORY REPOnT (Do not Wf. Re below)
Water of sahfac~:~e~,o~~ be free~ Coliform organisms
[] Fou.d
I-1 Total c~ group
[] u.suaa~e-- See bek3w
UNsurrAB~ FOR ANALysm-
wilhin ~30 hours of ~ (11)0 ~Xequired)
~ DAY
TYPE OF SYSTEM
BY
WATER 80URCE .... ¢
[] Well Wall Depih ~
[] Unsuitable --.~w~ below
UNSUITABI,,E FOR ' : ~ ' ~ ~'' '
ANALYSIS - PLEASE RF_~MIT '
[] ~ old. Sam~ not received [] ~j~ for analysis · 30 hours Of (Xill~ (100~::~