Park Place-LR 910617 CITY ZIP CODE
~PE OF BYSTEM iPub; c Systems OPl~
Public ~ Dairy ~ Distribution _ Raw
Individual ~ ~ttle~ ~ ~truct;on ~ ~heck
~ Soeciah ~
Ownershio~ ~{her information:
TIME AM/PM
WATER SOURCE
Z River ~ Lake
~ Well Well Depth
Chlorine Resioual ~
Coliform Orgamsms ~ Found
MF Coliform Count [presumptive1
LABORATORY REPORT (Do not write ~l~.low)
Water of satisfactory bacteriological quality should be fre~ from Coliform organisms
FO~T WORTH CITY HEAL'IN
DEPARTMENT
/l~ml
MF Coliform Count (¥erified) /100mi,
UNSUITABLE FOR AN~.~LYS)S-PLEASE RESUBMIT
[] Sample t~)f~,~not rece yeti [] On y one sampe per time and point of collection
within 30 hours of collection required
[] Date discrepancy or form incomplete
(See encircled item)
[] Quantity insufficient for analysis
(100 mi. minimum)
[] Leaked in transit L-- Other
[] Not an approved container
[] Heavy (silt/bacterial growth)(with coliforms) present,
possibly obscuring and compromising test results
[] Quantity too great to pern31t agitation
-
SEND RESULTS TO
ZIP CODE
SAMPLE IS WATER SOURCE
~PE OF SYSTEM
~ ~ Public ~ Dal~ : Distribution ~ Raw ~ River ~ Lake
~' Well ~otn
Individual ~ ~ttled ~nstruct~on Ch~ ~ Well
School -/' ~ Soeclal Chlorine Residual
LABORATO~ ~EPORT (~ not write ~low)
Water of~a~acteriological Guallty shoul~ De free from Coliform orgamsms
Coliform Organisms ~ Found
MF Coliform. Count (presumptive)
MF Coliform Count (verified)
FORT'WOI~H CITY HEALTI/
D £,- AR'£M El~t' LAB/iRATOR~
I100ml.
~ i100ml,
UNSUITABLE FOR ANALYSIS-PLEASE RESUBMIT
[]SamDle too old, Sample not mc. eived
within 30 hour~ of colleCtion
[~[:]ate d~crepancy or form incomplete
(~oo e~circied item)
[] Quantit~ Insuffloient for analysis
~ 1100 mi. minimum)
· [] Leakedln transit '
[] NOt an approved container
WA?ER BACTERIOLOGY ~ *
d Date
~'~ ~.~ ~ ~' Reported ~
~ SEND RESULTS TO: "
I~1/~1 ~[~1~1 151~ I [ I I I IJ I
Wat~.Sy~ Identification Number
~PE OF SYSTEM SAMPLE IS
~Pubhc SystemsOnly~ WATER ~URCE
~ Public Dairy ~ Distribution Raw ~ River ~ Lake
~ In~iv~ual ~ Bottled ~ ~nstr~ction ~ Check ~ Well Well ~pth
Own~shlp or other information: /
~BOflATORY REPORT (~ not w~e ~w)
~liform Organisms ~ Found st Found
MF ~liform ~unt (presumptive) ~ ~ /1~
MF ~liform Count (verlfie~) /l~ml.
' UNSUiTABi~E FOR AN ALYSiS. PLEASE RESUBMIT
· [] ~affiple too old. Samplenotrecoived [] Onlyonesamplep~rtimeandpointofcollection
~ithln 30 hours of collect[on t required
2~ [] D~edlscrepancy-~or form incomplete .[~ Heavy silt/bacterial growth with colitorms) present.
possibly obscuring and compromising test results
~ Quantity too great to permit agitation
L_ Other
(Se~nclrcled itent)N
Quen ty insufficient for analysis
} [] Not an approved container