Park Place-LR 910327 TER BACTERIOLOGY
No G19(rev 10-84i
Date and Time Rec'd
Sample'No,
Reported
ER SYSTEM COONTY '
SEND RESULTS TO:
NAME '
STREET ADDRESS (PO Box)
POINT OF COLLECTION COLLECTEO SY MONTH DAY YEAR
Water System Identification Number J I I Ill Il
TYPE OF SYSTEM SAMPLE IS
,pub,,c s~,s~ems On'w WATER SOURCE
Public -- Dairy -- Distribution -- Raw ~, River ~ Lake
IndiviOual ~ Bottled ~ Construction ~. Check -- Well Well Depth_
School Special Chlorine Resiclual
Ownership or other information:
Coliform Organisms L- Founcl ot
MF Coliform Count (presumptive)
LABORATORY REPORT (Do not write below)
Water of satisfactory bacteriological quality should be free from Coliform orgamsms
~'ORI' WORTH CITY IlEA/TN,
i~,,PAgI'MENT L~O~TO~¥
Found /
M F Coliform Count (verified)
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 anatys~s
(100 mL minimum)
~ Leaked in transit
,~ Not an approved contaiper
[] Only one sample pe~ time and point of COllectio
required,
[] Heavy (siltlbacte~ial §rowth) (w~th colilorm$> ~)r~
~ , Quantity too gre~t to permit agitation
~ Other