Riverchase(3)-LR 930831 (2)WATER BACTE~IOLOG y
Form No. G-I,~, er. 12/91) Texas Department of He,~.
Bureau of Laboratories
NAME OF WATER SY~EM ~ ~ / /
NAME
STREET ADDRESS (P.O. Box)
Collection I ~ I I~
MONTH DAY YEAR TIME AM/PM COLLECTED
TYPE OF SYSTEM SAMPLE I$
(Public Syst~ Only) WATER SOURCE
~'~ublic [] Dairy r~.Distribution [] Raw [] River [] Lake
[] Individual [] Bottled ~oflstruction [] Repeat [] Well Well Depth
[] School ~,. [] Special Chlorine Residual
Ownership or other information: ---
LABORATORY REPORT (Bo ll~t wrll~ below)
Water of satisfactory bacteriological quality mu~t be free from Coliform organisms
Coliform Organisms J~Not Found f ' ~
~Lj Found
[] Total colifeml gt'~up
[] Repeat samples required
[] Unsuitable -- See below
UNSUITABLE FOR ANALYSIS - PLEASE RESUBMIT
[] Sample too old. Sample not received
within 30 hours of collectbn
[] Date discrepancy or form incomplete
(See encimled item!
[] Leaked in transit
[] Other
[] Quantity insufficient for analysis
(1~0 mi. required)
[] Heavy (silt/bacterial growth) prescott,
possibly compromising test resull5
POINT OF C~L/OT ON
ZIP CODE
~PE ~ SYSTEM ~ (Pu~ ~y) WA~R SOURc.
~ublic ~ Dai~ ~ Di~rib~ ~ Raw ~ ~ver ~ Lak~
~ndividuaJ ~ ~led ~onsffu~ ~ Re~t ~ W~ ' Well D~
School ~ S~ial
Ownemhip or o~er informat on: C~ R~du~
~BO~TORY REP~e n~ wrl~ ~ ~
Wat~ ~ sa~sfa~o~ ba~edol~ qua~ ~sl ~ free from ~li~ ~sms
Coliform Organisms ~Not Foun~
~ Found ~
~ Tot~ ~o~ group
~ ....... . ..... ~~ ·
~ Re~al samples r~u~
~ U~u~le~ S~ ~w
UNSUITABLE FOR ANALYSIS - ~LEASE t~t.IBMIT '
[] Sample to0 old. Sample not receive¢l [] Quantity insuffieie~t for S~alys,;j
wi~in 30 hours of collection
-. (100 mi. required)
[] Date dis~epancy or form incomplete [] Heavy [silt/bactelial growlh)
CSee encircled item)
[] Leaked in transit possibly compromlsirlg test resu~
[] Other
[] UnsulL~ble
[] Sample too oki. ~ample nc~ reoelve<t
wltlfln 30 ho~a of colleC~on
[] Date discrepancy o~ form ktComplete
(See endrded Item)
[] Leaked In
[] Othe~
V
[] Quanl~y
(1 O0 mi. ~equ~red) '.
[] Heavy (silVOa~h)
· ~'91 ) Texas Dep~
~P ~DE
Data ~
~PE OF SYSTEM
~ I~ividu~ ~ Boated ~stru~o~ ~ ~epeat
~ School ~Well Well De~
Ownemhip or O~er information: Chlod~ ~Jdu~
Water of satJsfa~o~ ~ctedol~i~ qua~ ~t ~ flee fr~m ~lif~ ~g~sms
Coliform Orgsnlsms ~ot Found
~ Total ~ group
~ R~at samples required
UNSUITABLE FOR ANALYSIS - PLEASE ~IT
[] Sample too old, Sample not received
within 30 hours of COllection ~.~ I:~uan~f insu~Mit
[] Date discrepancy or form incompl~e
[] Leaked in transit
~] Other
tt · ~ no~ ~e
Wa erSys emi O No
NAME ~
TO:
STREET ADDRESS (P.O. Sox)
II /Tx [,, I
TYPE OF SYSTEM
(Pubic Sy&tlm~ Only) WATER SOURCE
[~flS'ublic [] Dairy [] Disblb~lk3sle~-[~ Flaw [] River [] Lake
[] individual [] Bottled ~tru~Jon [] Repeat [] Well Wail Depth
[]-School [] Special Chlodne Re~lual
Ow. nershlp or otiler informa/ion: --
LABORATORy REPORT,
~r~ ~ ~ ~) '
Water of sat~factory bacteriol~ qu~ ~1~ ~'~e from Coliform dmanisms
Coliform Organisms ~;~ Not Found i ~'~ .
~Found ~' .
,
[] Repeaf &~lmPles, requrreo
~ Unsuitable ~ See belo~f
UNSUITABI~_'I~)R' ANALySiS - PLEAS~ 'R~I~ . -
[] Sample too old. Sample not received. ' ;?~] Quantity n~ufficient fer~ll~Jalyals
w~mm 30 hours of collection (1 O0 mi, required) '
[] Date discrepancy or form incomp~ele
(See encircled Item)
[] Leaked in transit
[] Other
[] Heavy (silt/bacterial glz~4h) I:xesur.
pos~ibty compromialng teat resull~
'~ ..~ ~.. £' ~
~o not ~A ~ve th,s I,ne-- Ple~ pnnt w,~]t peaa
Water System I.D. No. NA~ OF WATER SYST~
N~ .......... ' ......
Time of ~ S*"- ' ~' ~' -' :
Co ~ction MONTH DAy Y~' ~'~'~ ~' - , ~ ~Y
(~ ~ ~ly) WATER ~URCE
~blic ~ D~W ~ ~n.'; , ~ Raw ~ River ~ ~ke
~ individual ~ Bo~led ~c~on ~ Repeat ~ Well Wea Depth
~ School ~ Sped~ Chlodne R~
~BO~TORY REPORT (~ n~ ~e ~1~)
W~e~ o1 saasf~oM ~er~l~ qua~ ~ ~ ~ ~om C~J~¢o~lsms
Coliform Organisms ~Not Foun0
~Found
required
[] Unsuitable ~ See ioelow
u NS U JTABIT'~{3FC)i"'~YSI8 -: _PLEA~qE
Sarape t~ old. Sample ~t r~iv~ ~ Qu~ insuffi~.~ysis
within 30 bourn of ~lle~
Date discrepancy or form in~m~ete ~ HeaW (sil~a~e~ ~) pre~
(See encircled ~em) '~ly compro~'~t
Leaked in [r~slt
Other
Date and
MONTH DAY Y~ ~ ~M ~OTEO ~Y
~ ~ WA~ SOURCE
TY~ OF 5Y~ (~ ~ ~.~)
~lie ~ Da~ ~ ~_~ ~ Raw ~ R~er ~ ~e
~ Sc~ ~ ~ ;~ Ch~r~e~l
Ownership or othe~ info~maUon:
LABORATORYREPORT (~en~ twlte below)
Wat&r o! satisfaclo~y bectedok~l quality m~,t be free from Coliform oeganisma
Col.o~m Orgenlom. J~Ne4 Fou.d
[] Total
[] Unsuilable-- See below/: ~
UNSUITABLE FOR ANALYSIS~-.~LI~ASE
SamF4o too oki: Sample no~ r~
wRhin 30 ~a of
Date di~r~y ~ f~m in~
[See ~rc~
Leak~ In
Oth~