W Sandy Lk Addn-LR050503City of £ewisvifle Laboratory ?
Water Bacteriology '
Na~ o~ Water S~tem County
Water System Idenbfication Number:
(Mo/Day.r) _
Billing "~E />~ ~-
· ~ TELEPHONE
TYPE OF E~ublic [] individual
SYSTEM: [] Other
SAMPLE I'-]Dis~but~on [] Special [~"~onstrO,~tion ~.~
IS:
[] Repeat for sample # ~
[] Recheck for sample #
[] Ot~er !:
WATER I1~ [] River [~ake [] Well
S~RCE: ~ ,
Weft bep~ Chl~ne Residual
(Colilert) E:Coli Present Absent
M.RN. Total Coliform /IOOML
UNSUITABLE FOR ANALYSIS: (This unsuitable sample must §e replaced within 24 hours,)
[] Form Incomplete (see attached item)
[] Sample too o~d, not received within 30 hours of collection
[] Excessive chlorine present in sample
[] Unsuitable container
[] Heavy, nomcoliform bacteria/silt present, possibly obscuring and compromising test results
[] Quantity too great to permit agitation
[] Quantity insuff~cien[~r analysis (100 mi minimum)
[]Other Analyzed by
Water of satisfactory qualily should bo free of Coldorm Organisms