PA9901-LR021028TARRANT COUNTY PUBLIC HEALTH LABORATORY
1800 University Dr., Ft. Worth, TX 76107
WATER BACTERIOLOGY Lab No. 48010 (617)871.7245
Date and Time Rec d.1 L; r „ r��+t0.
Sample No.
'J I b b' U t liepa t.
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NAME DFVATER SYSTEM - eA* cvy r
POINT OF COLLECTIONISAMPLE DESCRIPTION Water System I. No.
SEND
RESULTS
TO:
97Z- 113.53$
STREET ADDRESS (P.O. Box)
MiA TX 1 606 5
CITY (Zip Code)
912 - 1 123 -0 Cut
PHONE# COUNTY
Date and � 8 O ;
Time of
Collection Month Day / ✓ M Collected By
TYPE OF SYSTEM /S PL WATER SOURCE
[�ublic ❑Dairy ❑Raw C] River ❑Lake
❑Individual ❑Bottled AlrfUhA truction [:]Repeat ❑Well
[]School []Vend llSweetlChill Water Well Depth
�� Chlorine Residual
Additional Information:
0 ATORY REPORT (Do no write below) TECH
MMO -MUG
Membrane Filtration (MF)
MMO -MUG
PresencelAbsence
1100 nd. required)
Most Probable Number (MPN)
Col i orm Organisms �{
Found ! � XJ
Coliform Organisms
❑ Not Found
Coliform Organisms
❑ Not Found
'] of
Found
❑ Found
❑ Found
❑ Total Coliform group
Total Coliform/100 ml
Total
❑ Escharichia tali
E.colil100 nd
Coliform: MPNI100ml
❑ Repeat samples required
Fecal Coliforms1100 ml
E.cok. MPN1100ml
❑ Unsuitable -- See below
1 ❑ Unsuitable --See below
❑ Unsuitable -- See below
UNSUITABLE FOR
❑ Sample too old. Sample not received
within 30 hours of collection
❑ Date discrepancy or form incomplete
(See encircled item)
❑ Leaked in transit
❑ Quantity too great to permit agitation
❑ Excessive chlorine residual: mg1L
iSE RESUBMIT
❑
Quantity insufficient for analysis
1100 nd. required)
❑
Heavy (sgtibacterial growth) present,
possibly compromising test results
❑
Sample received on Friday
❑
Other
H -220 GPC -2190 REV. 6-97