Stonemeade-LR 930311Beautiful Future
_IL
......
y tern i.D. No. ~NAME OF WAT R ;STEM/ /
POINT OF
~ SubmJtter J.D, No.
SEND ~
RESULTS ~
TO: ~
Z~P CODE
T~ME AM/PM CO CTED BY
TYPE OF SYSTEM SAMPLE IS ~
IPub~Jc Systems Only) WATER SOURCE
~Public [] Dairy [] Distribution [] Raw [] River [] Lake
[] Individual [] Bottled ~C'~nstruction ~] Repeat [] Well Well Depth
~ School
[] Special
Ownership or other information- Chlorine Residual
LABORATORY REPORT (Do not write below)
Water of satisfactory bacteriological qualJ[y mus be free from Coliform organisms
Coliform Organisms ~ot Found
LJ Found
[] Total co,form grou~
[] Fecal coliform
[] EschErich~E COl~
[] Repeat samples required
[] Unsuitable _ See below
UNSUITABLE FOR ANALYSIS - PLEASE RESUbMiT
[] Samplo~oo ~ d Sample not rece red
with n 30 hours of collection '"'~ '~ - [] Quantity i~sufficient fo~ erlal,,~'
[] Date discrer~,~ ....... .~' ~o s
/~- · r x'-',ro/~a, mCOmpete ~ ~ (100 mi. required)
~,-,~u encircled tern [] Heavy (silt/bacteria~ growth) present.
[] Leaked in transit Possibly COmpromising test results
[] Other
Date and Time
Date
pen or .~ ,
ys em hD. No,
SEND ~
RESuLTs
TO:
Date and
Collection MONTH YEAR
TYPE OF SYSTEM
SAMPLE iS
/PubJic Systems Or~Jy) WATER SOURCE
~'Public [] Dairy [] Distribution [] Raw [] River [] Lake
[] [ndividua~ [] Bo~ied ~'Construction [] Repeat [] Well
[] School
~)wnership or other informat on' [] Special Well Depth~
· Chlorine Residual
LABORATORY REPOI~T (Do not write below)
Water of satJsfacto~ bacteriological quality must be free from Coliform organisms
Coliform Organisms ~(~t Found
[] Found 1'
[] Total coliform group
[] Fecal coliform group
[] Esche~fchia co/i
[] Repeat samples required
[] Unsuitable _ See below
UNSUITABLE FOR ANALYSIs _ PLEASE RESUBMIT
[] Sample too old. Sample not received
within 30 hours of collection [] Quantity insufficient for analysis
[] Date discrepancy or form incomplete (100 mi. required)
(See encircled item) [] Heavy (silt/bacter a/growth) present.
[] Leaked in transit poss/b y COmpromising test results
[] Other
WA~'I'i~I~,~G~i~OG¥ Texas Department of Health
Fonm No. G-I~ (Rev. ;~2/91~/ Bureau of Laboratories
Date
and
!.J ,~'~ I ~ Do not mark ~ ~ ~e--dpe~s~pH~vi~i~.~a?oi~tp~nortypewrlte{.
POINT OF OOLLECTION COUNTY
NAME t
STREE'r ADDRESS (P.O. Box)
CITY ZIP CODE
Collection DAY YEAR TIME AM/PM COLLECTED BY
SAMPLE IS WATER SOURCE
TYPE OF SYSTEM (Public Systen~s Only)
[~:~ublic [] Dairy [] Distribution [] Raw [] River [] Lake
[] Individual [] Bottled [~struction [] Repeat [] Well Well Depth
[] School [] Special Chlorine Residual
Ownership or other information:
LABORATORY REPORT (Do not w~ite below)
Water of saflsfactory,~_ct~,edological qual~ r~,ust be free from Coliform o~ganiSms
Co[ifom'l Organisms ~,,ot Found ~;{t~"'
f [] Found ",J
[] Total coliform group
[] Fecal coliform group
[] Escherichia~l! : _ ~ ~ ~ ~
[] Repeat samples required
[] Unsuitable -- See below
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 transit
[] Other /
[] Quantity insufficient for analysis
(100 mi. required)
[] Heavy (silt/bacterial growth) present,
possibly compromising test results