ST9502-LR 960424 (2) Texas Department of Health
WATER BACTERIOLOGY -.
' Bureau of Laboratories
Form No. G-19 (Rev. 2/93)
Date and ~me Rec'd. Date
Sample Ne.~': r-- .~. ,"
~ this line -- P ease pdnt with ballpoint pen or typewriter.
Water System I.D. No. -NAM'EVOF WATER SYSTEM
· - ' COUNTY
POINT OF COLLECTION
Submitter I.D. No. IIIIIII
SEND L' ~'<V>F'I',I Ig)kTh/I;L~l '1 I I I I I I I [ I I I I I I I I I I I
NAME
RESULTS ~L2~'i_~ ~l~l~l,~P~J,ol,,I 141/IH~'I I~1~1 ICI,-Ixl STREET ADDRESS (P.O. Bo~)
Dateand ~ ~--~ ~
Time of ~ ~.[~
Collection MONTH DAY YEAR TIME AM/PM
SAMPLE IS
TYPE OF SYSTEM (Public Systems Only)
.~Public ' [] Dairy [] Distribution [] Raw
[] Individual [] Bottled .~Construcfion [] Re?at
[] School [] Special
Ownership or other information:
COLLECTED BY
WATER SOURCE
[]River [] Lake
[] Well Well Depth
Chlorine Residual
LABORATORY REPORT (Do not write below)
Water of satisfactory bacteriological quality must be free from Coliform organisms
Coliform Organisms J:~lot
"5 ound
Found
[] Total coliform group
[] Escherichia colT ...... ~
............. ' "7.:' :-: :.:':T~;':--- ':'' '
~_.--::. ---: ':: .... : '-:::-'- '?- [] Repeat samples required
. [] unSu~a~ e-- See.be!°w"
UNSUITABLE FOR ANALYSIS - PLEASE RESUBMIT ~.
[] Sample too old. Sample not received [] Quantity insufficient for analysis
within 30 hours of collection (100 mi. required)
[] Date discrepancy or form incomplete [] Heavy (siltJbactedal growth) present,
(See encircled item) possibly compromising test results
[] Leaked in transit
[] Other
WATER BAC~'ERIOLOGY Texas Department of Health
Bureau of Laboratories
Form No. G-19 (Rev. 2/93) . .
. . .~ ~. Date~ .
Date and Time Rec'd. ~ ' .... Re rted
~ pO
Sample No. ..... ~ , ~ n~,,~,,-~ .
., ballpoint pen or typewri!er. ........ ..
NAI~IE-OF WATER SYSTEM
Water System I.D. No.
COUNTY '~
POINT OF COLLECTION ..... i~
I 't"IIi ' '"
SEND
NAME ........
RESULTS ~
,,,,,, I,z,.co
Time of
Collection yF_,~,R
MONTH DAY
TYPE OF SYSTEM
~_ ~ublic [] Dairy
[] Individual [] Bottled
TIME. AM/PM
~ SAMPLE IS WATER SOURCE
(~ub!ic Systems Only)
[] Distrit~u§on [] I~w [] River [] Lake
.~Construction [] RePeat [] ~ell Well Depth --
[] School [] Special Chlorine Residual
O~r other inf°rmaficn: ............. · - .
LABORATORY REPORT (Do not write below) '
Water of satisfactory b .a~teriol°gical quality must be free from Coliform organisms
Coliform Organisms ~L~ot Found -'i'~ '
[] Total coliform group
~: .......~ ...................... [] RepeM sampies required
[] Unsuitable~- See below
UNSUITABLE FOR ANALYSIS - PLEASERESUBMIT
[] Sample too old. Sample not received [] Quantity insufficient for analysis
within 30 hours of collection
[] Date discrepancy or form incomplete
(See encircled item)
[] Leaked in transit
[] Other
(100 mi. required)
[] Heavy (silt/bacterial growth) present,
possibly compromising test results