Devonshire 2-LR 920707 Bureau o¢ I aboratcdes
Water ~tetem I.D. No. NAME OF WATER SYSTEM.
oF co c oR CO .TV
11111111
HAME
STREET ADDRESS CP.O.
CITY I ~ ZIP CODE
Date and
Col~rl MONTH DAY TiME AM,~M COU. ECTED BY
SAMPLE I~ WATER SOURCE
TYPE OF SYSTEM (Public Systems Only)
[] Public [] Dairy [] Distribution [] Raw [] River [] Lake
[] Individual [] Bottled [] Construction [] Repeat [] Well Well Depth.__
[] School [] Special Chlorine Residual
Ownership or other information:
LABORATORY REPORT (Do not write below)
Water of setisfadory I~ctericto~l quality must be free from Coliform organisms
llfeem Orgeel~ ~ Not Found
[] Found
[] Total
[] Fecal
[~R~at samplo~ requked '
[] Unsuitable-- See below
UNSUITABLE I:O ALYSIS - PLEASE RESUBMIT
~ Sampia too old. Sample not received
within ~0 hours of collection
[] D~te discrepancy or form incomplete
· (See endrcisd item)
[] Leaked in transit
[] Other
[] Quantity insufficient for analysis
(100 mi. required)
[] Heavy (sllt~oacterial growth) present,
possibly compromising test results
WATER BACTERIOLOGY ~ ~: "~ ~ ~.~'~eau olLaboratedee
FormNo. G-19(Rev. 1/91) ~ i ~ ::j~_.ILj · ii
Date
Water System D No ~ NAME ~1: WA'I~R SYSTEM ~.
..' , -
ciw;[ r / ~
C~n ~H DAY Y~ 'i CO
SAMI~.E I~ WATER SOURCE
TYPE OF SYSTEM (Public SystemaDnly)
[] public [] Dairy [] OistC/outlon [] Raw [] River [] Lake
[] Individual [] Bottled [] Construction [] Repeat [] Well Well Depth
[] School [] Special Chlorine Residual
Ownership or other information:
LABORATORY REPORT (Do not write below)
Water of satislactory I~ctericicgtcal quality must be ~ree from Coliform organisms
Collfmm Organl.ma ~:] Not Found
, : [] Fecal :: ~ . ,.
[] Unsuitable -- See below
UNSUITABLE FOR ANALYSIS - PLEASE RESUBMIT
[] Sample too old. Sample no~ received
within 30 hours of co[~ecUon
[] Date discrepancy or form incomplete
(See em=kctsd item)
[] Leaked in transR
[] Other
[] Quantity insufficia~t for analysis
(100 mi. required)
[] Heavy (siit/'oactorlal growth) present
possibly compromising test results
Texas Department o~ Health
Bureau af Laboratodee
Date and Time Rec'd.
Sample No~..
'~ i Doebt~meL~e~°vethh#ne. FqeMe'P{fltwlthbM~&°lntP~°'~ )'P'~'~';;,~': .
warm Sy6tem I.~. No. NAME q~F WATER SYSEIM
RE$UtTS ~l~'
Time of t~ I ' il
Collection - COLLECTED BY
MONTH DAY Y.E~ ~E AM~M
~AMPLE I~ WATER 8OUFICE
TYPE OF SYSTEa (Public S~mteme Only)
[] public [] Dairy [] Distribution [] Raw [] River [] Lake
[] Individual [] Bottled ~onstruction [] Repeat [] Well Well
[] School [] Spe~at Chlor~e Residual
LABORATORY REPORT (Do nM twlte belaw)
Water of satisfaeto~ l~iceedological quathy must be free lmm Coliform o~gonisms
Coliform Organl~ne ~] Not Found
[] [] Total
Found
[] Repeat samples required
[] Unsuitable -- See below
//
UNSUITABLE FOR ANALYSIS - pLEASE RE$1.~BIdlT
within 30 hours of colledion
[] Date ~:aepancy (x fo~m incomplete
(See ~ item)
[] Leaked In transR
[] Quanti~ ineuffidentfm aualysis
(100 mi. required)
[] Heavy (silt~aea~qat growth) present,
~ oompmmlslng t~t results
[ ] ~ark Up Plans [ J Plans
[ ] Pr~Ke
Copy of Himicee [ ] Coj~/ of ~_CCer [ ] Sptcificitiots
Chanp order [ ~
0 Aequm~d m edmaed
0 Ae~m~ed m hoed
0 ~eumud tot ~muc~mu
0 Nm & F~r~ard To:
0 Subm~ ee~m tnt deoOmlon
O~efm emucUd~ma
0 Note & Kq~ To: