Park Place-LR 910313NAME OFWATER SYSTEM '~ COUNTY
SEND RESULTS TO:
)INT OF?~OLLEC~rlOi~ ~ COLLECTED I~
TIME AM/PM
OF SYSTEM ~'~AMPLE IS
IPu~ ¢ Systems Onlvl WATER SOURCE
~ Dairy Z Distribution ~, Raw ~ River ,.~,-La~e
'~ Ind'wdual ~ Bottled ~,LConstruction ~. Chec-'~'~ (~ ~ Well WeltDepth
~ Schoo~ ~ Special (~llorineResidual
Ownership or other information
LABORATORY REPORT (Do not il/itl below)
Water of satisfactory bacteriologic.al quality shoutd be free from Coliform organisms
t:OR~ WORI'I~ CIT~ I~L'[~
Ot A TML: I' L BOI / TOI Y
Coliform Orgamsms ~' Found ~Not Found
MF Coliform Count presumptive)
MF Coliform CPu n t hlel~'/ted)~
UNSUITABLE FOR ANALYSIS-PLEASE RESUBMIT
[] Sample too old. Sample not received
within 30 hours of collection
[] Date discrepancy or form incomplete
tSee encircled item]
[] Quantity insufficient for analysis ',.~
,100 mi. minimum]
[] Not an approved container
[] Only one sample per time and point of collection
required
[] Heavy (sutlDactenal growth) (with collforms) present
possibly oDscprmg and compromising test results
[] {~t~ntlty too great to permit agitation
~ Other
WATER BACTERIOLOGY
Date and Time Rec'd
Sample No.
NAMEOFWATERSYSTEM
SEND RESULTS TO:
L,,I bPl,41vl/l~]-Id/Irlvl Io1~1 IclolPIPIrklcl I I
~lol~l~l~l I I I I I [ ITx. 17~DI/NI'~
ZIP CODE
Water System Identification Number
TYPE OF SYSTEM
~ Public ~-- Dairy
Individual Z Bottled
School
MONTH YEAR ,~ TIME AM/PM
Ownership or other information:
SAMPLE IS
Distribution -- Raw
Construction -' Cheil[
SOeC~el
WATER ~OURCE
River ~ Lake
Well Well ~th
ChlotiM ~lOuel __
LABORATORY REPORT (De riel trite bMew)
Water of satisfactory bacteriological quality should be free from Coll/O~m o~ni~m~
/
L~Not Found
Coliform Orgamsms ~ Found
MF Coliform Count (presumptive) I100mL
M F Coliform Count (~rTfied~ ~ ~ .
UNSUITABLE FOR ANALYSIS-PLEASE RESUBMIT
[] SamDle too old, Sample 3or received
within 30 hours of collection
[] Date dlscreoancv or form incomolete
ISee encircled item
[] Quantity insufficient for analysis
,100 mi. minimum
;ORT WQRTlt Cfl'Y HEAL~
[] Only one sample per time and point of collection
[] Heavy (slit/bacterial growth)(with collforms) present,
possibly obscuring end compromising test results
~ Quantity too great to permit agitation
~ Othe[
Date and Time Rec'd
Sample No.
SEND RESULTS TO:
Y-~ I~,~1 vi/15 l- I~1 ~ Irl. y'l
NAME
POINT OF COLLATION" COLLECTED BY
Water Syste~ Identification Number
TYPE OF SYSTEM_
~ Public ~ Dairy
~ ~ School
COUNTY
lolrl b-lol~Pl~ g-I I I
I(-IolPI/' -g:tz-I I t ] t I I I'r,...l.7t,,;l,, 1/ I? I'I-'I-T -I
MONTH DAY YEAR
SAMPLE IS
Distribution Raw
Construction ~_ ~ ~
Spemal
Ownership or other information:
WATER SOURCE
~- River ,~ Lake
~- Well WelIOel3th : ~'
Chlorine Residual
-LABORATORY REPORT-(Do not write below)
Water of satisfactory bacteriological quality should be tree from Coliform organisms
coliform Organisms -- Found ~"~dt Found
M F Coil for rn .Count (presu rapt ive) ,.~ .?~10~?~, ~) ~.~ ~'~ ~.~I
MF Coliform Count (verifie~) ~'~ II~ml. ~'
UNSUITABLE FOR ANALYSIS-PLEASE RESUBMIT
~ Sampletooold. Sampienotreceiv~ ~ Onlyonesample~rtlmean~polntofcollectlon
within 30 hours of collection required
~ Date discrepancy or for~ incomple e ~ Heavy {silt/bacterial growth) (with coliforms) present,
(See encircled item) possibly obscuring a~d compromising test resuqs
~ Quantity insufficient for analysis ~ Quantitytoogreattopermitagitation
{1~ mi. minimum)
~ Leaked in t~nsit ~ Other
~ Not a~ a~ro~ed contai~r ,.
WATER BACTERIOLOGY ;
Sample NO. "''~
TER SYSTEM
SEND RESULTS TO: '
/;~)~ NT OF COLLECTION
COLLECTED By
.~TYPE OF SYSTEM ~ ~AMPLE IS
,~'ub,,c Sys,*r~s o~v, WATER SOURCE
.~-- Public Z Dairy -' Dish'ibution -- Raw ~- River ~, Lake
-- Individual ~ ~ttl~ ~ ........
~ ~nstrucbon ~ Check ~ Well Well~pth
~h~l Special
Ownership of other information: Chlorine Residu~ -~
LABORATORY REPORT (Do not write below)
Wafer of satisfsciory bscteriological quality should be f~'ee from Coliform organisms
~ 48~)1Q
Coliform Organisms -- Found t Found
MF Coliform Count (presumptive) ~_ _/1OCtal.
M F Cch form~C_~ount (ver~ fled "~ / l~)Om].
U '
NSUITABLE FOR ANALYSIS-PLEASE RESUE3Mi-r
~ Sample too old. Sample not receiveo ~ Only one sample Der time ~d ~olnt of collection
Within 30 hours ot collection
Date 31screDancy or form incommme
(See er~clrcled ~lem~
Quantity Insufficient for analysis
(100 mi. m "'mum]
Leaked m transi!
Not an approveo contair~er
Heavy (sdt/~acteria growth) (with coliforms) Dresenl
Quantqy too great to permit agitation
Other
WATER BACTERIOLOGY
Form NO G-~9 (rev 10-84)
Date and Time Rec'd
Sample No,
iter
NAME OF WATER SYSTEM
SEND RESULTS TO:
STREET ADDRESS IP O Box)
Water System Identificat,on Number [ I I ~:~ I
SAMPLE IS
Z Distribution ~ Raw
~-~ Construction ~ Check'"'
TYPE OF SYSTEM
.~ Public ~. Dairy
~ Individual ~ 8ottled
~- School
Ownership or other information:
TiME AM/PM
WATER SOURCE
!" ~ Lake
~.~?~ River
~. Wel,,.~l Well Depth
Chlorine Residual __
LABORATORY REPORT (Do not writa ~low)
Water of satisfactory bacteriological Quality shouici be free from Coliform organisms
Coliform Organisms ~ Found
MF Coliform Count (presumptive)
MFCohform Co u nt {v;ecHied),
Found
FORT WORI*H Cl
UNSUITABLE FOR ANALYSIS-PLEASE RESUBMIT
[] Sample too old. Sample not received
within 30 hours of collection
[] Date discrepancy or form incomplete
(See encircled item)
[] Quantity insufficient for analysis
(100 mi. minimum)
[] Leaked in transit
[] Not an approved container
[] Only one sample per time and point of collection
required
[] Heavy (silt/bacterial growth) (with coliforms) present,
possibly obscuring and compromising test results
~. Quantity too great to permit agitation
~- Other
WATER BACTERIOLOGY
Form NO G-19 (rev. 10-84)
Sample NO. Date
DO not mark above this line
TYPE OF SYSTEM SAMPLE IS
~ Public ~ Dairy ~ Distribut~o~ -- Raw
individual ~ Bottled ,'~C°nsJ~ruction ,~ Check
Schoo, ~
Ownersmp or other information:
WATER SOURCE
-- River .~ Lake
~ Well Wail Depth
Chlorine Residual
'~?~ABOJ:IA,~.~ REPORT (Do'not write ~low)
Water ° f sat'stact°ry b~?~l~i°'t*~al Quality sh°ul" be free from Coliform drgamsms
Coli,o,~ Organi,., ~ Pound ~Founo ,~ ~0~" ~'~ ~~
MF C°lif°rm C°unt (presumptive)~/l~mI 0[~[~ ~[~ ~[~ ~
MF C~iform Count ~ -' ~/~ml ~, ~t~ ~.7
within 30hours of COllection
Date a~SCreDancy or form mcomolete
Not an apprOved container
Other