Gateway BP (1.1)-LR 901030 FWT~ER~ACT~LO~ Y
Daleom:lTIme Rec'd I~" / ~e
~lo~. 3 R~rt~
8END RESULT] TO:
(~/ lC~Hf¢.Hl, I I I/.Iv :~ I I I I I I I I I'1 I I I I
I~'lr..'l I~loHI 14.171/:11 I I II I II I I I I I I I I
I~INT OF COLLECTION COLLECTED BY
Wa~er System identification Number
!FI'PE OF SYSTEM SAMPLE IS
[~ublJc [] Dairy ] J Distribution U Paw
[] I~dlvld~l [] BOttled [-[]"~)nstructidn [] Check
[] ~chool I~ Special
Ow~lershlp or other InformaUon:
WATER SOURCE
[] River ~*'l~ike
[] Well Well Depth
Chlorine Residual
LA~ORATORY REPORT (De mol lille bMmv)
Water et utisfactory bacteriological quality Should be free from Coliform organisms
Coliform Organisms [' I Found ~ 73 Not Four~l
MFColIIorm Count (presumptive) I1OOml.
M ~,F~#forl~ Count (verified) I1OOml,
U,~t~IT~BLE FOR ANALY~I~*PLEA~E RESUBMIT
[] ?~llfe dllcreplll~ m' fom~ Incomplete
~ ~Ol~cl~l Illml
[] ~lOullllltylnmdPclenl for iflllyols
~110~ mi. minimum) -
[20t~e~