Huntington-LR 930517order I~l
GOPZES ~ ~.
O~lrm
O~iii
Iu~m~IiI
[ ] IgiciIli
No. Q.'lg (Rev. 12/91) ~ i~ureau oi Laboratories,
Da~t and Time Rec'd. Date
~ME O~ WA[
cou~fr~
POINT OF COL~CI'ION
STRI:ET AODRES8 (P.O, Box)
ZiP
Date and
Collectlon~a~ DAY
TYPE OF sYSTEM
[] Dairy
D spe~-,
SAMPLE IS WATER ~OURCE,
(Pu~lc Systsms O~ly)
[] DistflbuSon [] Raw [] River [] Lake
J~C, onslmction [] Repeat ; [] Well Well Deptfi
Chlorine Residual.
LABORATORY REPORT (Do not write
Water of .a~ab-~e?ologlcalq~ ~st/lbe~free.lr°m Coliform organisms
[] Total coliform group [] Fecal coliform group
[] EscheK~la coil
[] Unsuitable-- See lae~i~v
w~ln ~0 hours of colleClJon
[] Date discrepancy or form Incomp~ete
(See encircled Item)
[] Leaked in transit
[] O~er
i~NSUITABLE FOR ANALYSIS - PLEASE RESUIMIT
(100 mi. required)
[] Heavy (silt/bacterial grow~) present,
possibly compromising test results
Fom~ No. G-19 (Rev. 12/91) ~ /~ '~'
D~eandTimeRec'd. r~'~u ~U,LU D~te
N ~. ,..'?'~. L _ ........... P~.d .
8END
RE~ULT~
TO:
waw ~ i.o, No. ~ NAME OF WATER ~
I ~4~r~,/,~,,/~'~,/~, ,,~,1 I,~ ,, ,, I
~,,~,.;~.~l.o.~. Il I I I I I
14 ,~,~-~ ,~,~,,,,, ' '" ' ' ' '" I
~ ~ (P.O. ~)
c~ ~P ~
Date and
TYPE OF SYS'TEM
~IPLE I~ WATER SOURCE
(eut~e Sy.tems ~ly)
i'-} Ois~ DRaw i'-1 River r-I Lake
[] ~ Chlodne neaidual
Ownemtdp or other I~:
LABORATORY REPORT (1~ nm write bMow)
Water of satisfac~oglcal quality must be kee from Coliform organisms
[] Found ~' '
[] Fecal coliform group
[] Repeat samp~ requ~ed
[] Unsuitable-- See below
UNSUITABLE FOR ANALYSIS- PLEASE RESUIMIT
within 30 houm of collection
[] Date discrepa~-'y or form incomplete
(See M~clrcled item)
[-[ Leaked In l~anslt
[] Other
~ QuanUty imulfldent for ~r~lysls
(100 mi. required)
[] Heavy (MIt~ctMtet growth) present,
possibly compromising test result~
CiTY ZIp CO~E
~E ~ 8Y~ ~ ~
WA~R
~U~E
~ Al~er ~ ~
~ I~u~ ~ ~ ~ ~ R~at ~ WMI Well D~
"~ ~ ~ S~ Chl~ne Residu~
Ownership or o~n~ informl~on:
LABORATORY REPORT (Do not write batow)
Water of satlsfactofl~bact~ologlcal q~.u~ity ~u~t be free from Coliform organisms
C4~llform Orglnim ~lrCot Fou ncl '~/~,,...C..~/
Il'Found ~
[] Total coliform
group
[] Fecal coliform group
[] unsuitable-- See.l~w ,.
UNSUITABLE FOR ANALYSIS - PLEASE RESUIMIT
wflhin 30 ~m of coflec~o~
0 Date discrepancy or form imorrc31ate
(Sea encircled item)
[] Leaked In 'lranslt ~
[] O~er
[] Quan~ly insufficient for analysis
(100 mi. required)
[] Heavy (allVoactetal growth) present,
possibly compromising test results
WATER BACTERIOLOGY Te~ Dep~tment M Hea~
Form No. G-I O (~. 1~1) ~u d ~
~ ~ ~ ~'d. ~;"' ~.~
~* ~-- ~., r II~
W~ ~ I.D. ~. ~ ~ WA~
R~L~ I I~1 ~1~ IS~I I I I I I I I I I I I I I I I I I I I I
Date and
~ S~ One) WA~R ~U~E
0 ~ 0 ~1 Ch~ R~I
LABORATORY REPORT (Do nM w~e below)
Water of satlefactoq~ bac~j~x~1nal qual~ must be free from CoMorm organisms
[] ~ecat
[] P~ eam~ roquked
[] Urmultable-- See below
UNSUITABLE FOR ANALYSIS - PLEASE RESUBMIT
[] Sample too old. Sample no~ received
wlUlln 30 houm of ~olectlon
[] Date dl~:mpancy ~ form incomplete
(sae endrded item)
[] Leaked In bansit
OOth~
[] Quantity insufficient for analysis
(100 mi. required)
[] Heavy (MIVoactmtal growth) pre~,
possibly oompromislng teat results