Gateway BP (1.1)-LR 901101· Det{I em:l Time Rec'd ~.~ Oete
~ OF WA~R SYa'~SM '~OUNTY
SEND RE~ULTS TO:,
~l~ OP SYSTEM
~ Public [] Dairy
[] ~lndivld~l [] Bottled
hoo,
SAMPLE IS WATEI1 SOURCE
Distribution [:] Raw [~] River
r~/Construction [J Check [] Well Well Depth
Special Chlorine Residual
OW~/tership or other information:
LABORATORY REPORT (Do not write below)
Water oi satisfactory bacteriological quality should be free from Coliform organisms
FORT WORTH CITY HEALTH
MF ~llf~m ~unt (pmsumptive~~ml.
~$UIT~LE ROR ANALYSIS-PL~SE RESUBMIT
~_~ Only one sample per tlme and point of collection
required
[] Heavy (lllt/b~clerlal=
possibly test results
[] Quantity too
[] Other