Parks Coppell-LR 930324 (2)SEND
Water ~.r~. I.D. No. :. NAME OF WATER ~ --.
: ~ , ~ ..- ~LD.~: L. f I .?.~: .:
(lO~m[.~
[] H.avy (=~b.~e~'ial ~row~) pre,~'~,
Date andTime Re~'d.! ,:-. ~ ,.-~ ,_ Date
,,sample No. ~.-- - .............. ' - ' ~ ''
~END
RESULTS
TO:
1.t~mte and
eof 1,31 L:, I I fl:
Cuil~ctkm MONTH DAY Y~R ~ME AM~M
SAMPLE ~
~PE OF SYSTEM (Pub~ S~t~ Only)
~blic ~ Dai~ ~ D~kibuflon ~ Raw
~ S~d ~ Sp~al
~n~sh~ ~ o~
Bureau et Leboretodes
Do mx ma~ above Ihb line -- Pleses pHnt wlh bellpolht pe~ o~ ~1~4v~e~.
W~ ~t~ I.D. No. NA~ OF WA~R S~M
COLLEOTEO BY
WATER SOURCE
[]River [] Lake
[] Well Well Depth
Chlorine Residual
LABORATORY REPORT (Do not write below)
Water of satisfac{of~ bacte~olegteal quality must be free from Coliform organisms
Col.ofm Organl~me ':~:~ot Found ~Yi~
'~ ' [] F°und El Tote~ ~
.......... [] Fecal , ~ .......
[] Unsuitable -- See below
Date and Time Rec'd. i' :,, .:.: -. ~ ~.[.)Date ~
-- .' ,.' L/ ~., DO not mark abov~.thi.~ line.:-T P.[e~. e D~,nt. ~,~ll~pen ~ typmvriter.
Water System LD. NO. NAME OF WATER SYSTEM
5. POINT OF COLLECTION COUNTY
: .SubmitterLD. No. I IIIIIII I
STREET ADDRESS (P.O. Box)
TO:
CITY ZiP CODE
Date and
Timeo, I, 1
Collection
MONTH DAY YEAR
TYPE OF SYSTEM
[~u bile [] Dairy
[] Individual [] Bottled
[] S~:,h. ool [] Special
TIME AM~PM COLLECTED BY
SAMPLE I$
(Public Systems Only) WATER SOURCE
[] Distribution [] Raw [] River [] Lake
[~nstruction [] Repeat [] Well Well Depth
Chlorine Residual
ownership or other information:
Coliform Organisms "~ot Found ~ {~
' [] Found
[] Total coliform group
[] Fecal coliform group
[] Repeat samples required
[] Unsuitable -- See below
UNSUITABLE FOR ANALYSIS - PLEASE RESUBMIT ~
[] Sarape too c~l. samPle not received - [] Quantity in. suffic{ent for analysis
within 30 hours of coitec{ion (I 00 mi. required)
[] Date discrepancy or form incomplete [] H~avy (sift/bacterial growth) present,
(See endrcled item) possibly compromising test results
[] Leaked in transit
LABORATORY REPORT (Do not write below)
Watpr of satisfactory bacteriological quality must be free from Coliform organisms
UNSUITABLE FOR ANALYSIS - PLEASE RESUBMIT
[] Sample b3o old. Sample not received
within 30 hours of collection
[] Date discrepancy or form incomplete
(See encircled item}
[] Leaked in transit
[] Other
[] Quantity insufficient for analys~s
(100 mi. required)
[] Heavy (silt/bacterial growth) present,
possibly compromising test results
Bureau ~ Laberatodes
re Ran'd ! c~ ..... ,.. Date
TIME AM~M COLLECTED BY
SAMPLE I$ WATER SOURCE
; OF SYSTEM (Public System~ Only)
t [] Dairy [] Distribution [] Raw [] River [] Lake
Jual [] Botaed [~onstructton [] Repeat [] Well Well Depth
)~ [] Special Chlodne Residual
~p of o~er information:
LABORATORY REPORT (Do not ~lte below)
Iter of sMisfaC~°rx b~ctedological quality must be ~ree from Coliform organisms
,Organ,--. ~_ot Found
i [] Found ~.~
[] Total
[] Fecal ..... .. -
................. :: :' :' "" [] Rapa~t ~;~i~ r~ir"d
[] Unsuitable-- See below
U TABLE FOR ANALYSIS - PLEASE RESUBMIT ~>
~ too old. sample nd received . [] Quantity imufficlant for analysis
n 30 houm o~ collection (1 O0 mi. required)
~ dlesmf~ncy of fofm incomplete [] H~avy (silt/bacterial growth) present,
, em:trcled item) possibly compromising test results
[ed In transit
N~E
STRE~ ADDRESS (P.O. Box}
CI~ ZIP CODE
Date and
=meof I, 1
Collection
MONTH DAY YEAR
TYPE OF SYSTEM
[~u blic [] Dairy
[] Individual [] Bottled
[] School
TIME AM/PM COLLECTED BY
SAMPLE I$
(Public Systems Only) WATER SOURCE
[] Distribution [] Raw [] River [] Lake
[]~nstruction [] Repeat [] Well Well Depth
[] Special Chlorine Residual
ownership or other information:
LABORATORY REPORT (Do not write below)
Water of satisfactory bacteriological quality must be free from Coliform organisms
Coliform Organisms '~ot Found ~
' [] Found
[] Total coliform group
[] Fecal coliform group
: ~ : .-:: -~ ::? .: ~ :: ,:~ .:E]Escherfchiacolf:: .
[] Repeat samples required
[] Unsuitable -- See below
UNSUITABLE FOR ANALYSIS - PLEASE RESUBMIT
[] Sample too old. Sample not received
within 30 houm of collection
[] Date discrepancy or form incomplete
(See encircled item)
[] Leaked in transit
[] Other
[] Quantity insufficient for analysis
(100 mi. required)
[] Heavy (silt/bacterial growth) present,
possibly compromising test results
Fo . G-19 (Rev. 12/91) Bureau of laboratories
WATERBAC';rERIOLOGY - ' "' Texsa Del~mant of Health
Foem No. G-19 (R'ev.-1/gl) ...... Bureau o~ Labomtodsa
Dale and Time Res'd. ~ "* ~ ' ' - ~ ,- · .- Dale
Wa~ System I.D. No. NAME OF WATIER S'k'STEM
No. I , , , , , , , I
/'Date and
nm. of
{~Public [] Dairy [] Distribution [] Raw [] River [] Lake
[] Individual [] Boffied ~onstructlon [] Repeat [] Well Well Depth.__
[] Scho~' [] Special Chlorine Residual
Ownership or other information:
LABORATORY REPORT (Do not ~wlte below)
Water of satisfactory bacteriological quality?nust be free from Coliform organisms
Col.on'11 Organlam, ~lct Found
[] Total
· ' - ' [] Refle~t samples required
_.) [] Unsuitable-- See below
UNSUITABLE FOR ANALYSIS - PLEASE RESUBMIT
[] Sample too old. Sample no{ received [] Quantity ir~uflicient for analysis
within 30 hours of collection (100 mi. required)
[] Dele discrepancy or form incomplete [] Heavy (alif/baclerial growth) present,
(Sea erlcircisd item) paeal~y compromising test results
[] Leaked In transit
SEND
RESULTS
TO:
Date and'13me Rec'd. ~7~ ..... , Date
~ ~'~ ..... - Reported
SamR~ No.f ~ ,.~ ~.
~' '"'.~ D~ i~t mark above this lirle.-~-~easeprint with baJlpatht pen or typewriter
.,-":_' ;o~;,...r.~ ,'::; :,-
Water System I.D. No. NAME OF WATER SYSTEM
POINT OF COLLECTION COUNTY
Submaer~.D. No. [ I I II I I I I
NAME
7T '
STREET ADDRESS (P.O. Sox)
CITY ZIP CODE
Date and
,meof 7-1 1=
Collection
MONTH DAY YEAR.;TIME AM/PM COLLECTE[ BY
SAMPLE IS WATER SOURCE
TYPE OF SYSTEM (Public Systems Only)
[~ublic [] Dairy [] Distribution [] Raw [] River [] Lake
[] Individual [] Bottled [~onstruction [] Repeat [] Well Well Depth
[] School [] Special Chlorine Residual __
Ownership or other information:
LABORATORY REPORT (Do not write below)
Water of satisfactory bacteriological quality F~ust be free from Coliform organisms
CollformOrganisms .~_ot Found
, [] Found
[] Total coliform group
[] Fecal coliform group
[] Escherichia coil
[] Repeat samples required
[] Unsuitable -- See below
UNSUITABLE FOR ANALYSIS - PLEASE RESUBMIT
[] Sample too old. Sample not received
within 30 hours of collection
[] Date discrepancy or form incomplete
(See encircled item)
[] Leaked in transit
[] Other ~
[] Quantity insufficient for analysis
(100 mi. required)
[] Heavy (silt/bacterial growth) present,
possibly compromising test results