Mercantile-LR031022CITY OF LEWISV~! {.F_ LABORATO~YV- WATER BACTERIOLOGY
/ Name bi Wat®r System ~' County ~
Point el Colle<~ion
Billing/
Repelling
Address:
~ ~, .
Collected By ~ Time
~ (MO/Day~)
NAME ~
TELEPHONE( ," )
Water System Identification Number
TYPE ~[~'Pu~c [] Indiv~ua~
OF
SYSTEM: [] (~hor
SAMPLE [] Distribution [] Sdecial E:]~C0nstruct~n
IS:
[] Repeal for sample it .
[] Recheck fei sample it
[] Other .
WATER []Rk, or ..E~ []Wen :~ .
SOURCE: Well depth Chlorine R?'sidual
RESULTS: ~' -
Present ~ ~
· (Colilert) E:Coli. Present .~ ~
/IOOML
MP.N. Total Coliform --/IOOML
(Colilort) E. Colt. - ~
Membrane Filter/Fecal Coliform: 1st Dil. I_ mi 2nd ____/__mi
Avg. _/ mi
Unsuitable For Analysis:
[] Form Inmml~te (~ee eodmled item)
[] Sample too old, riel reo~ ,T~Athln 30 houm of co~bctlon
[] Exss~Ive cNod~ pr~e~ i~ samCe
[] UssublY~malalm~ ;~,/ ~ .,
[] Heavy. no~ colif*3~n bacl,ma/aill pm~ent, pe~bfy ~)b~cu~ng and corr~'orr.s~ng teal results
F'l (~canllly ir'~uflt~er~ l°r mnm)/~'~ ( t O0 nl mmmum) ~/