ST0001-LR020221 TARRANT COUNTY PUBLIC HEALTH LABORATORY
tBO0 University Dr.. Ft. Worth, TX 76107
WATER BACTERIOLOGY
Do ~ot Mark Above This Line ·.--Please Print Below with BALLPOINT PEN OR TYPE~ITER:
NAME
~ESULTS Si~i ADORES~ (P.O, Box)
~.t, aid
Time of
TO:
CITY
PHONE S COU~
Collection Month Oay
TYPE OF SYSTEM
E~'~ub[ic ODairy
r--hndividual f--TBottled
f-"lSchool r~lVended
(zip Co,el
Additiun~l Informatiun:
Year TIME -
SAMPLE IS
[] Distribution [] Raw
[]Construction i-]Repeat
I--I GlycollSweet/Chill Wafer
[~Other
AM/PM Collected By : t
WATER SOURCE
[]River []Lake
[]Well
Well Depth
Chlorine Residual
LABORATORY REPORT (Do no write belovvl TECN
Membrane Filtration (MF}
Coliform Organisms
~ [] Not Found
[] Found
group Total Coliform/lO0 mi
~ Fecal CollformsllO0 mi
i [] Unsuitable .. See belnw [] Unsuitable -- See below
· ' UNSUITABLE FOR ANALYSIS-PLEASE RESUBMIT
Sample too old. Sample not tec.e!ved
t~' [] Oate discrepancy or form incomplete
(See encircled iteml
· , [] Leaked~t~an~t :~"
[] 'Ou~liy tOO §real to pmmit agitation
' [] Excessive chlorine residual: mpJL
MMO-MUG
Most Probable Number (MPN)
Coliform Organisms
[] Not Found
[] Found
Total
Coil!or? .MPNIIOOmL
E. colk ~MPNIIO{Jml
[~3 Unsuitable -- See below
[~. Q,u.~?~tity insL~fficieflt for analysis
(100 mi. tequlre~ :; '"
TARRANT COUNTY PUBUC HEALTH LABORATORY
: 1800 Univers~y Or Ft Worth TX 76107
WATERBACTERIOLOGyr [ LabN~o, 48010 "* (81'7)87t-7246
Do Nor Mark Above This Line *----Please Print Below with BAE~.~)INT PEN OR TYPEWRITER:
NAME £ ~/STEM * ~
POINT OF COLLECTION Watm System I.O. No.
%' ,,./,' I.' ,..,,, ,,., ::
NAME
SERO ~3D,,2 ~__o,.-,4/,"l'~:
RESULTS STREET ADDRESS {P.O. Box)
TO:
PRONE
. O~te~fid
Time of
Collection
TX 7._,-'""<::3
LZ~p Code)
COUN~f
Month Day
TYPE OF SYSTEM
~]l~'~lic []Dairy
r--]Individual r--TBottled
[::]School []Vended
Year TIME . AM/PM Collected 8¥
SAMPLE iS WATER SOURCE
[-'l Distribution r--IRaw i--IRiver ~'~lLake
..~onstruction [~]Repeat E]Well
['--I GlycollSweetIChiO Water Well Depth -
r--lUther Chlorine Residual
Additional Information:
LABORATORY REPORT ID0 no write below)
· - TECH
group
[] Eschar~ohio c~/i
E~ Repeat samples r~u,red
[] Unsuitable .- See below
Membrane Filtration (MF)
Coliform Organisms
E~ Not Found
[] Found
Total Cotiforml100 mi
£.co/~100 mi :. ;
~' i'l Fecai"Coiiferm~llOomi
[-] Unsuitable - See below
MMO-MUG
Most Probable Number (MPN)
Coliform Organisms
[] Not Found
[] Found
Total
Cofiform: MPNIIOOmi
· . "~.~. ~' ' ~P~lldd~i
[] Unsuitable -- ~ee,l~elow
UNSUITABLE FOR ANALYSiS-PLEASE RESUBMIT
Sample too old. Sample not receive~d.
Leakedi~tra?t .- ~ .~'
Exceswe c~d~ fesMuaE_ ___~L
[] Quantity insufficiem for analysis
iff)0 mi. ~equired)
[] Heavy (silUbaCtl~al growth) presmlt.
posslldy comPomising test results
[] Sample rec~Ved on Friday ~
E]'
H-219 GPC-2190
NAME OF WA~ER~YSTEM
POINT OF COLLECTION Water System LO. No.
NAME
TARRANT COUNTY PUBLIC HEALTH LABORATORY
WATER BACTERIOLOGY tBoo University Dr., Ft. Worth, TX 76107
Lab No. 48010 (8171871-7246
Date and Time Rec'd
Oate
Do Not Mark Above This Line ***--Please Print Below with BALLPOINT PEN OR TYPEWRITER:
RESULTS STREET ADORESS (P,O, Box!
TO:
CITY
Collection Month Day Year TIME
TYPE OF SYSTEM
~Public ~Oa}ry
~lnd~vidual ~8ottled
~School ~Vended
Additional Informatiun:
AM/PM Collected By
SAMPLE IS WATER SOURCE
[--]Distribution [~Raw I'--lRiver I-]lake
~ZrConstruction [~] Recent []Well
[] Glycol/Sweet/Chill Water Well Depth
r~0ther Chlorine Residual
LABORATORY REPORT (Do no write below)
,-=,,,u~ade F Itratmn (MF)
Coliform Organisms
~3 Not Found
[] Found
Total Coliform/100 mi
_ £ co/¢ 100 mi
Fecal Coliforms/100 mi
[] Unsuitable .. See below [] Unsuitable .. See below j
UNSUITABLE FOR ANALYSIS-.PLEASE RESUBMIT
[] Sample [oo old. Sample not received
within 30 hours of collection
[See encircled if em)
[] Leaked in lransit
[] Ex cessive chlorine residual:
H-219 GPC-2190
TECU
MMO-MUG
Most Probable Number {MPN)
Coliform Organisms
[] Not Found
[] Found
Total
Coliform: MPNIIOOml
E. coli. __MPNIIOOml
[] Unsuitable .. See below
[] Quantity insufficient fm analysis
(t00 mi. required)
[] Heavy (silt/bacterial growth) present.
possibly comp~o~sing test ~esults
[] Sample recewed on Friday
[] Othe~