Riverside Church-LR010723Date a~d Tm~ , .) .,-) Date
NAME OF WATER SYSTEM
POINT OF COLLECTIONtSAMPLE DESCMPTION
NAME /
STREET ADDRESS (P.O.
TO:
¢-k Code)
COUNTY
Collection Month COy Year TIME I.~ AM/PM
TYPE OF SYSTEM SAMPLE IS
r']Public C~Dairf E~ Distributiml [-1R~w
I'-Ilndivldual E:] Bottled ~] Coeet laotian r-]Repeat
i'--18cflool r-lvendnd ~] GIycoltSweet/Chl]l Wotw
Qot,~
Wot~ Systml I.D. Ne.
Idolsl
~ATER $OUSSE
~1 D~th
UNSUITABLE FOR ANALYSIS-PLEASE RESUBMIT
[] Sample too old. Comp4enotrecldved
within 30 hm~s of ce41ectioo
[] Oat e dlsc~epadlcy of fomt btcompbtte
(See eec~lwi item)
[] Leaked bt ttaflsit
[] Coanthy too great to p~fl~t a~tatioo
[] Oua~tity h~uffbt~t f~ aoaty~
(100 n~ requkedl
[] Heavy (~bactm~l powth) p~t,
pess~y con~fomisk~ test results
[] ~ reee~ved ee F~day
M1 LABORATORY REPORT (Do no write bdowl TECH
"~ M MUG Membrane Filtration [MR MMO.MUG
Prsuenc rAbsence Meet Probable Number (MPN)
Coliform Orgee~ ~ /"~ Cdiform Organisms Coliform Organisms
Not Found '..~ [] Not Farad [] Not Found
~ Tota~ordorm group Total CeSfem/TOO nd Total
'l~g,~h/w c~ Ecor~lOO mi Colifofl~ MPNI1OOml
[] Repeat samples requbed __Fecal Colifotms/tO0 nd £.c'o~ MPNI1OOml
[] Unsuitable - See below [] Unsuitable -- See bdow [] Unsuitable -- See bek)w