Sand Point-LR 920420Collection
'I:~*PE OF SYSTEM SAMPLE IS
(Public Systems Only) WATER SOURCE
--/L~'Public [] Dairy [] Distribution [] Raw '[] RNer [] Lake
[] individual [] Bottled [~onstruotion [] Repeat [] Well Well Depth
[] SchOol [] Special Chlorine Residual
Ownership or other information:
LABORA'I~ORY REPORT (D~ ~not ,,'wire below)
Water of ~etislact~0ry bacteriological quality mu~ be free fr~n Coliform organisms
Co,. .m o,.g..,..,. [ ot Found
[] Total .:.
[] Repeat samples required
UNSUITABLE FOR ANALYSIS - PLEASE RESUBMIT
[] Sample too old. Sample not received
within 30 hours of collection
[] Date discrepancy or form incomplete
(See encircled item)
[] Leaked in t(ansit
[] Other ~
[] Quantity insufficient for analysis
(t00 mi. required)
[] Heavy (silt/bacterial growth) present,
possibly compromising test results
WATER BACTERIOLOGY Texas Department of Health
Fo~n~le~l~g ( Rev;~/~..~ Bureau,~.aboratoflos
Data and T'~me,~edd .... Date '.
Sample No. : ' RepOrted
Do ne{ mar above this line -- Plse~e print with ballpoint pen or typewriter.
Water System I.D. No. NAME OF WATER SYSTEM
POINT OF COLLEC31ON COUNTY
SubmtherI.D..o. I I I I I I I I I
lc,.
SEND 1~41'1 I I I I I I I I I I I t I I I I I I I I I I [
1211DISL ISlfL~thlSt-J [ I I I I I I I I I I I I I I I I I I
STREET ADDRESS {P.O. Box)
TO: ~Y~!aS:~.fl].~l I I I , i , ,~l ITx 17~06~,D1''~ I
Date and
Time of
COLLECTED BY
SAMPLE I~ WATER SOURCE
TYP~ OF SYSTEM (P~bac Systen~ Only)
[~lg'ubife [] Dairy [] Distribution [] Raw [] River [] Lake
[] Individual [] Botifed [~onstruction [] Repeat [] Well Well Depth
[] School [] Special Chlorine Residual
Ownemhip or other lofo~maifon:
LABORATORY REPORT (Do nol ~wlte below)
Water of satisfactory bacteriological quality must be free from Coliform ~ganisms
Colltm'm Otgantamt ~/Not Found
FORT WORTH
Total CITY
[] DEPARTM[ . HEIiLTH
[] Repeat samples requked ~c~]O, .
[] Unsuitable -- See below
UNSUITABLE FOR ANALYSIS - PLF-ASE RESUBMIT
[] Sample too old. Samplo no{ received
within30 hours of collection
[] Data discrepancy o~ form incomplete
(See em~rcled item)
[] Other
[] Quantity insufficient for analysis
(100 mi. required)
[] Heavy (siR/bacterial growth) present,
possibly compromising test results