Securelock-LR040412 (2)Point of Collection
Billing/
Reperling
Address:
- WATER BACTERIOLOGY
ColleCted By Date Time
(Mo/Day/Yr)
STREET ~-/~i ~,,~.~,~/~¢z/-~ ~.~j,~'
C~TY ~/;~ ~ ~[X*S' P~/~
TELEPHONE( ~/? ) =2~/~.~'~/ (~c~)
Water System Identification Number
TYPE
[~P ublic [] tndividual
OF
SYSTEM: [] Other
onstrucbon
SAMPLE [] Distribution [] Special
IS:
[] Repeat for sample #
[] Recheck lor samp{e #
[] Other
WATER [] River [] Lake [] Well
SOURCE:
Well depth Chlorine Residual
Avg.
Unsuitable For Analysis:
[] Fon~ Incomplete (see encircled ilew
[] Sample too old, not received within 30 xfllection
[] Unsuitable container
[] Heavy, non coliform bactede/s~it present, possibly obscuring and comp Its
[] Quantity too great to permit agitation '
[] QuentW insufficient for analysis (100 mi minmum)
[] Other*
Analyzed by