Town Center BP-LR010517TARRANT COUNTX PUBLIC HEALTH LABORATORY
WATER BACTERIOLOGY
1800 University Or., Ft. Worth, TX 76107
❑
Lab No. 48010 18171871.7245
ate and Time Reid.
within 30 hours of collection
ample No q
.
Date
t
fleported
Do Not Mark Above This Line - - -- Please Print Below with BALLPOINT PEN OR TYPEWRITER:
(4
NAME OF WATER SYSTEM
Month Gay
r
TYPE OF SYSTEM
SAMPLE IS
ZIPUhlic
[]Dairy
❑Distribution ❑flaw
]Individual
❑Battled
POINT OF COLLECTIONISAMPLE DESCRIPTION
'
❑vended
/t]GtycollSweetlChillWater
Other_
❑ Other
Y
- Water System I.D. No.
r
RECEIVED
NAME
SEND r� r
gip p
iESULTS S ERT ET ADDRESS IP.0. Drug
TO:
n
Ji
TX
CITY
(Zip Code)
PRONE ff
COUNTY
WATER SOURCE
[]River []Cake
[]Well
Well Depth
Chlor R 'd I
ditional Information: ne as ua
LABORATORY REPORT I u m no write below) TECH
PresencelAbsence
sliform Organisms
Not Fdund
] Found
❑ Total Coliform group
❑ Escpeiichis tali
❑ Repeat samples required
] Unsuitable See below
Membrane Filtration (MIN
Coliform Organisms
❑ Not Found
❑ Found
Total Coliform1100 ml
_E. cold 100 ml
_Fecal Coliforms1100 ml
❑ Unsuitable See below
Most Probable Number (MPN)
Coliform Organisms
❑ Not Found
❑ Found
Total
Coliform:_MPNI100ml
Ecoli.• _MPN1100m1
❑ Unsuitable- See below
]
Sample too old. Sample not received
❑
Quantity insufficient for analysis
within 30 hours of collection
(100 ml. required)
]
Gate discrepancy or (arm incomplete
_
Unction
Month Gay
Year TIME
TYPE OF SYSTEM
SAMPLE IS
ZIPUhlic
[]Dairy
❑Distribution ❑flaw
]Individual
❑Battled
Construction ❑Repeat
]School
❑vended
/t]GtycollSweetlChillWater
Other_
❑ Other
WATER SOURCE
[]River []Cake
[]Well
Well Depth
Chlor R 'd I
ditional Information: ne as ua
LABORATORY REPORT I u m no write below) TECH
PresencelAbsence
sliform Organisms
Not Fdund
] Found
❑ Total Coliform group
❑ Escpeiichis tali
❑ Repeat samples required
] Unsuitable See below
Membrane Filtration (MIN
Coliform Organisms
❑ Not Found
❑ Found
Total Coliform1100 ml
_E. cold 100 ml
_Fecal Coliforms1100 ml
❑ Unsuitable See below
Most Probable Number (MPN)
Coliform Organisms
❑ Not Found
❑ Found
Total
Coliform:_MPNI100ml
Ecoli.• _MPN1100m1
❑ Unsuitable- See below
]
Sample too old. Sample not received
❑
Quantity insufficient for analysis
within 30 hours of collection
(100 ml. required)
]
Gate discrepancy or (arm incomplete
_
(See encircled item)
El
Heavy (siltibacterial growth) present,
]
Leaked in transit
L
possibly compromising test results
]
Quantity loo great to permit agitation
❑
Sample received on Friday
]
Excessive chlorine residual:_mglt
❑
Other_
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