Gibbs Station 1-LR 921005Form No. G-19 (Rev. 12/91) Bureau of I.~boratmles ~.' '
Date and TIme Rec'd. _ ......: .... - ~ Date
Sample No. ~ ~ .... - ' ~ Reported
Water Sys~nl I.D. No. NAME OF WATER SYSTEM
SEND
RESULTS
TO:
POINT OF COLLECTION COUNTY
S..~mW~'I.D.~. J , I , , , , J I
NAME /
STREET ADDRESS (P.O. Box}
cr~'Y
ZIP CODE
. I--I Lealmd In tmnait
[] Repeat aam~e~ required
[] Unsuitable ~ See below
UNSUITABLE FOR ANALYSIS - PLEASE RESUBMIT
[] Sample toe old. SamlXe not received
[] Date ~ or fo~m incomplete
(See encircled Item)
[] Quantity insufficient fo~ analy~a
(100 mi. required)
[-] Heavy (ailt/bactef~ growth) p~ent,
Ovmemhlp or other information:
LABORATORY REPORT ~Do not v~lte below)
Wate~ of salt sfactofy I~tl~ologicai quality ~ be flee from Coliform organisms
Coliform Organlam~ ~ Not Found - ~'
[] Total colitorm group
SAMPLE IS WATER SOURCE
TYPE OF SYSTEM (PuUlc Systems On;y)
[~1~C [] Dairy [] Disatb~tlon []'Raw [] River [] Lake
[]Individual []Bottled [:~i~citon []Repeat []Well We#Depth ..
[] School ~. [] Special Chlorine Reaiduai