Gateway BP (1.1)-LR 901106WATER BACTERIOLOGY Sureeu OI LsbOlatorles
DateandTImeRec'd ' ~. ,_ Date
Sample No. Reported
SEND RESULTS TO:
B...i/~i~iF..I~I Iq/,Lv'_t~l~l I I I I ! I I I I I I I Iq
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Water System Identification Number
SAMPLE IS
PYubE OF SYSTEM
Iic [] Dairy '
[] Individual [] Bottled
[] School
(PubhC Sy$1ems Only)
[] Distribution J:} Raw
[~'~onstructlon ~} Check
WATER SOURCE
[] River
[] Well WelIDepth --
[] Special Chlorine Residual
Ownership or other Inforh~atlon:
LABORATORY REPORT (Do not write below)
Water of satisfactory bacteriological quality should be free from Coliform organisms
FORT WORTH ClT~
Coliform Organisms [ ~ Found [ ) Not Found
MF Coliform Count (presumptive)- I100ml.
' MF Colll~orm__C..o~u.01 (.verified) ~- ~ I100mL -
-~ ~'~'-~ ;l~'Antl= FOR ANALYSIS-PLEASE RESLI~MIT-:~'~ .
~ ..... ~ 'V d - ..... [] Only one sampl~ per time and point of collection
[] Sempe .....
'erie row~h)~"*~"~'~"~ present,
[] Leakedintransit