Dry Clean City-LR020204 CITY OF LEWlSV1LLE LABORATOi~Y - WATER BACTERIOLOGY
.... llected 8y~ ~' ' 'J"~ Date Ti~
~o (Mo/Day/Yr) ~
BiltingJ NAME ~ ,
Reporting STREET ~' '~ '~
Address:
CITY
Water System Identification Number
TYPE ~,~[~_ u blic [] Individual
OF [] Other
SYSTEM: --
SAMPLE [] D~ribution [] Special
iS:
[] Repeat for sample #
[] Recheck for sample #
[] Other
[~.Construction
WAT~R [] River ~Lake [] Well
sOURCE: Chlorine Residual __
METHC LTS:
~sentJAbsent: Total Coliform Present - Absen~
MPN
(Co[[lert)
Unsuitable For Analysis:
[] Form Incoml~e (see encircled item)
[] Sample too ~ nol received within 30 hours of co~tectk~n
[] ExCeSSWe chlodoo p~esenl in sam~e
[] Unsuitable ce~si~e~
[] Heavy, non c=oliform bacteria/silt present, pessary obscuring and compromising tes~ resulls
[] Quantity Ioo greal to perm# agdation .
[] Quantity insull~ie~l for analysis (100 mi miP, rnum) ~ . ~,,{j~ ,
[] Other ( ,
Analyzed,by