WA0101-LR050914Wbt ? Bacteriology
· Lab Spec;men #
SAMPLE IDENTIFICA T/ON__
"U.L,CWATE. SYE ..D 0/\, ,
I ~ ~ (RE6~IRED)
PUBLIC WATER SYSTEM NAME (-,"~ /'~//
TO ~ C~ ~ Samp~ ColI~: ~ ~O~r
SAMP~ SITE / CO~C~ON DA~ ~ ~ME
(Sample should
LABORA7
Test
TARRANT COUNTY PUBLIC HEALTH
1!D1 S. Main St., Ft. Worth, TX 76104
USEPA Lab No. 01471 (817)321-4750
COUNTY 1 I '
rs present) ~)
collected on this date
~]Colilert MPN r~MTF [~Membrane Filtration
[~Found /100mi
coli ~ :,2
[] Found I
H-220 GPC-2190 Rev06-04 COPIES: CUSTOMER. LABORATORY. TCEQ
Water Bacteriology
TARRANT COUNTY PUBLIC HEALTH
1101 S. Main St., Ft Worth, TX 76104
USEPA Lab No 01471 (817)321-4750
SYSTEM TYPE ~AMPLE TYPE
r~lPdvate~ndividual [~nstmcfion ~S~al
~r . DRe~t ~ ~mp~ ~
DISINFECTANT RESIDUAL (Mandato~) ~.~ ~ ~ mg/L
WATER SOURCE
•Free Chlorine
[~oramine (Total Chlorine)
(Sample should not be collected/f no residual is p~esent)
SAMPLE
II Coliform
H-220 GPC-2190 Rev06-04
IP/A r~c~ile. MPI~ ~]MTF [ ~ Membrane Filt~ttO~
E~Found /100mi
•Found
Analyst Initials:
COPIES: CUSTOMER LABORATORY. TCEQ
wfitei- §acteriology
SAMPLE IDENTIFICATION
TARRANT COUNTY PUBLIC HEALTH
11~01 S. Main St·, Ft. Worth, TX 76104
USEPA Lab No. 01471 (817)321-4750
PUEUCWATE. SySTEM,B I i ,
~e ~ (REQUIRED)
PUBLIC WATER SYSTEM NAME
Se.d Name i i
COUNTY
Phone / ? ~' ~
To be checked by SaraH, Col~ E~owner/Pws r--]Operator
SAMP~ SI~ I COL~C~ON DA ~ and ~ME
[~ Privale/Individual [~sPeClal
E~Other [] Repeat for sample #
DISINFECTANT - ~
re.dual is present)
Number
~ Not Write Below)
Test I~ E] Colilerl MPN
Coliform
R/ATER SOURCE
[]Groundwater
114/e#)
(Lake, Rived
[]MTF r']Membrane Filtration
-"]Found /100mi
[]L
[] Fou~ld
Analyst Initials:
W t'e'r i lacteriology
COUNTY ( ~ , !,I, % .r '~
TARRANT COUNTY PUBLIC HEALTH
11~O1 S. Main St., Ft. Worth, TX 76104
USEPA Lab No. 01471 (817)321-47'g~
SAMPLE IDENTIFICATION
PUBUC WATER SYSTEM ID ?
PUBLIC WATER SYETEM NAME ~"
SAMP~ S~E / CO! 1 ~C~ON DA ~ a~ ~ME
OISINFECT~T: ~. ~ ~L ~ Em Chlo~.e
(Sample should n~ ~ ~sent) ~ ~iorami~ ~o~1 Chine)
ORGANISMS:
[]Colilert MPN E]MTF []Membrane Filtration
[]Found /lO0ml ':
i ~herichla col/ ~ '
i E~OT Fo.~d [~FOund /100mt ~
~s~ble ~r ~na~sis (S. ~1~) Ana~st InElele:
SAMPLL~NSUI~ABLE FOR ANAL YSIS
w ter Bacteriology
TARRANT COUNTY PUBLIC HEALTH
11Q1 S. Main St, Ft. Worth, TX 76104
USEPA Lab No. 01471 (817)321-4750
SAMPLE IDENTIFICATION
PUBLIC WATER SYSTEM ID l.,~ ///:-/
PUBLIC WATER SYSTEM NAME (:~"'/:::) ~ / ':~ /, ~
To be ch~knd by Bamp,~ Collec~r: I--IOwner/PWS
SAMPLE SITE/COLLECTION DA TE and TIME
?? d' :',
]'~Opefator [] Other ~ ~/.,
Sampler NameJPhone:
S. YSTEM TYPE SAMPLE TYPE
i'--IOistribuUon [] Raw: we~l #
D Private/Individual [~onstrucfion ~lspec;al
[] Other [] Repeat for sample #
r--lolflec
tiI~ATER ~OURCE ,~
~/Ve#)
(Lake. Ri~' ~
DISINFECTANT
RESIDUAL
(Mandato~)
rng/L
[]Free Chlorine
[:~,~l~mine (Total Chlorine)
Coliform
PlA •Colilert MPN E--]MTF []Membrane Filtration
E::] Found /100mi
[]Found I100ml /~2
Analyst Initials:
H-220 GPC-2190 Rev 06~)4 COPIES: CUSTOMER, LABORATORY, TCEQ
' ~V TARRANT COUNTY PUBLIC HEALTH
Bacteriolo . 1101 S. Main St, Ft. Worth, TX 76104
USEPA Lab No. 01471 (817)321-4750
SAMPLE IDENTIFICATION
PUBLIC WATER SYSTEM ID ~_..' ¢'/- COUNTY
Seven digifs (REQUIRED)
PUBLIC WATER SYSTEM NAME
Sam~ Street Address ~ '1 : i /?
~MP~ ~1~ / COL~C~ON DA ~ a~ ~E
(Lake,
DIBINFECTANT RESIDUAL (Mandato~) ~ o 0 mg/L
[_~mfomhl°rine
mine (Total Chlorine)
I Coliform
i P/A []Ccrilert MPN
]Found
E~MTF []Membrane Filtra[<xl
SAMPLE I
[]Sam~e t~o old NOt received withir~ ~0 h c,*a ~s Of COll~Cbon
E~Quanfity insuffide~t lot analysis (1~0 mL required)
]Form incomplete I dam dis~epancy (CIRCLE etTors)
E~ Oth~' reason: DESCRIBE
H-220 GPC-2190 Rev 06-04 COPIES CUSTOMER, LABORATORY, TCEQ
~ Water
/ , . Bacteriology
SAMPLE IDENTIFICATION
PUE"CWATERS~STEM,O ;r~,/L~. ~ cou.~_ b,:~/to _~
PUBLIC WATER SYSTEM NAME C~//g ,.~ .t /
. _ , .,~
. To~mp~ll~: ~ ~O~ ~ ~r ~ ~
TARRANT COUNTY PUBLIC HEALTH
1101 S. Main St., Ft. Worth, TX 76104
USEPA Lab No. 01471 (817)321-4750
IINATER SOURCE
rr~ Groundwater
~urface water
(Lake, River)
E~] Free Chlodne
J'--JChlocamine (Total Chlorine)
SAMPLE SITE / COLLECTIO~I DA TE and'TIME
o-~.co,,.~: ~o/ /~. o ~
Sampler Na~e/P#one:
Below)
[] Found /100mi
OFou.d .OOm,
Water Bacteriology TARRANT COUNTY PUBLIC HEALTH
1101 S, Main St, Ft Worth, TX 76104
USEPA Lab No. 01471 (817)321-4750
SAMPLE IDENTIFICATION
PUB"CWATERS,STE.,D
PUBLIC WATER SYS~M NAME
SAMP~ SITE / co'Echo
SYSTEM TYPE
[] Private/Individual
WATER SOURCE
DISINFECTANT RESIDUAL (Mandato~) ':'_-. _.
(Sample should not be colle~J~ if no res~ual ks present)
LABORA TORY,~OI~ [J3~ Not Write Below)
Test Meth~l~sed: ~[~ ~i~rt P/A [~C~iler~ M.~
COUF ~11 ORGANI~I ~
~.L I~OT FOU~ []Found
SAMPLE UA
mg/L [] Free Chlorine
E~lloramine (Total Chlo~ne)
E~MTF E~Memb~ane Filtratio~ ~-
Analyst Initials:
s~]rTABL E FOR ANAL YSlS (This unsuitable sample must be replaced ~in 24 h~ J
H-220 GPC-2190 Rev06-04 COPIES: CUSTOMER, LABORATORY, TCEQ