Gibbs Station 2-LR 930907Date and
Collect~n
MONTH DAY
I'~PE OF S~
O~h~p or o~er inf~n:
UNSUITABLE FOR ANALY~
[] Sample too old. Sample not I~:eived
within 30 hours of a311eclJon
[] Date discrepancy or ~'m inc~mp~et~
(See encircled item)
[] Leaked in transit
[] O~er
WATER BACTI~RIOLOGY
Form No. G-19 (Rev. 2/93)
Sample No.
W~ter System I.D. NO.
~U~etitt~' I r~. NO.
SEND
RESULTS
TO:
C~Y
Date and
Collection MO;e'n.I DA",'
,~ TYPE OF SYSTEM'~:
~'Pubiic [] Dais,
[] IndJvidua~ [] Bottled
~ Sample too old. Sample no~ receive~
within 30 hours of ~
[] Date discrepancy or fo~m incomplete
(See encircled item)
[] Leeked in ~ansit
[] O~,er
WATER BACTERIOLOGY
Form Igo. G-lg (Re~. 2/93) ~..
SampLe No. ' f' '~
Wa~ Sisera LD. No.
SEND
NAME
RESUL'r~
C~T~
r r' Bureau of ~
-'~at e and
Collection. --
TYPE oF
~ubac ,i"lD~v/
[] IndividuaJ
Ownership or othM
Fort G-lg (Rev 2/93) , .., -. Bureau of La~3ratones
Water System ~. No,
~1~
TO:
Date and
Collection uo~n~ D~¥
~PE OF
~Pub~
~ I~ividu~
~ership ~ o~r i~on:
~Y
Water
WA '
.: Chlodne ~
UNSUITABLE
[] Sample too olcL Sample not received
within 30 houm of colleclioa
[] Date discrepancy or form incomplete
(See encJrded
[] Leaked in transit
[] Other
F' · No. G-19 (Rev.
Sample No.
Bureau Ol Laborato,'~ ....
Water Sys.lem i.D. NO.
Submitter I.D, NO.
SEND
NAME
RESULTS
STREET ADDRESS
TO:
CITY
Date and
Collection ~Y
TYPE OF SYSTEM
[] IndividuaJ '-I ~ottied
Ownership or other information:
· CoJifo
UNSUITABLI
[] Sample too old, Sample not
within 8~ houra of collection
[] Date discrepancy or form incomplete
(See encirded item)
[] Leaked in lrar-mit
Other