Gibbs Station 1-LR 921015f ] ll~ttfttttim
O,~l~mmmmlmm~mm'mml O~ ' ~ Pl.l'l Im'~mmmml
O,Alsmemd m mmml 0 IMmmlt~ emlWmm Imm. ~lmmlmmmimm~
OIImmmllmm'mmmmem O- - m I~ I m_
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~ BACTERIOLOGY - : ' Texas Department of Health
Form No. G-19 (Rev. 1/91) Bureau of LahoratoHas
Sample No. Reported
SEND
RESULTS
CITY
Submltterl. O. No, J J I I I I I I J
_l~l/Jcl I ~.:~] L'],('.,I I I I I I I I , I I I I I I I . I I J
L~._[q I IFI I [.141~PI }/-lbl-q I I I I I I I I I I I . I [ I
Date and
Coflection
MONTH DAY YEAR TIME ' I~M~M COLLECTEO BY
TYPE OF SYSTEM SAMPLE IS
(Public Sy~term Only) WATER SOURCE
[~blZ~blic [] Dairy [] Distribution [] Raw [] River I~ Lake
[] Individual [] Bottl~ E~.~onstructlen [] Repeat [] Well Well Depth
[] School [] Special Chledne Residual
Ownershi;: or other information:
LABORATORY REPORT (De not mite below)
Water of satisfactory bacteriological quality must be free from Coliform organisms
Catlform O~gan,--. ~F~.F°undand "'~J~/J~OR~ ~OR~ C[T~ "F..~LT~
[] Fo~ 4~I0
[] Repeat samples required
[] Unsuitable-- See below
UNSUITABLE FOR ANALySIs - PLEASE RESUBMIT
[]$ampletcootd. Sample not recelved [] (10Oml~ .
wRhin 30 hours of collectlrm QuantHy Insufficient for analysis
[] Date discrepancy or f~m incomplete [] Heavy (~llt/bactorla! gl~Mh) present,
(See el~ctrcled Itmn) po~J:dy eon~ofomlsing tee~ results
[] Leaked In Irenslt - ........
S~aample No. ~ Reported
, DO nOt ~tark above tfli~ ~n.e..L_ ple~,e i~nt with ballpoint pen o~ ty~ewr er.
i .. ~* ' * . ~*, NAME OF WATER SYS'I~EM
~ PO,NT OF COU. ECT~ON '--' C'OU'N~,'
NAME
ZIP CODE
~ate and
meo, [ 21
TYPE OF SYSTEM SAMPLE ~
(Public Sy~em~Only) WA~R ~URCE
~blic ~ ~ ~ Dis~ibution ~,~aw ~ River ~ L~e
~ indMdual ~ ~o~ ~s~u~an ~ ~et ~ Well Well Oep~
~ ~h~l ~ S~ial Chlddns ~esldual
~ O~ership or other informa~on: ~ -
W . . LABORAYUfiy REPORT (Do not write below)
ater oT satisfactory ~ba~eriological quality must be free from Coliform organisms
Coliform Organisms .~rl~ot Found ~, 2,/~,F-~-
~ U'Found
· '~ ~ [] Total coliform group
[] Fecal coliform group
[] Esche#chia coli
[] Repeat samples required
[] Unsuitable -- SeeJ~w .
UNSUITABLE FOR ANALYSIS - PLEASE RESU~IMIT
[] 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 (siltroactedal growth) present,
possibly compromising test results