Valley R Center-LR 891129WATERBACTERI~ ~'GY t~' [ 0 ~¥['~'/"~ Tex&$Departme~tofHe~ltb
F~m NO. G.19 (rev. 10-~) ~ Bureau of La~ratories
Date and Time Rec'd , , Date
~mple No. ~ ~ '~ Reported
~AME OF~ATE~YST~,~ ~ ' ' ' '--'" ....
SEND RESULTS TO:
I,~ ~1~].~ I~1 I I I I I I I I il
~ ~TRE~ADDRES ( , · ) ....
'~1~1.1~/]~ I~l I I I~tx.l~L~/191-~
[TYPE OF SYS~'EM
Public [] Dairy
~--~ Individual [] Bottled
~ SAMPLE IS
Distribution ,[~ Raw
C~nstruction [] Check
[] Special
WAT~OURCE
[] River ~J Lake
[] Well WelIDepth--
Chlorine Residut~l
[] School ,
Ownerehiporotherinformatlon: /~,~/~ ~' L~-~.~;~ ,,'~//~,~/t~ ~
LABO"ATO"Y REPO"T (~ not write "l°w'(~*~z
Water of satisfactory bacteriological quality should be free from ~oliform organisms
Coliform Organisms [] Found [~Not Found
MF Coliform Count (presumptive) O I10(
M F ?~.o liform Co u n t ~(v~-i fiec~) I10(
UNSUITABLE FOR ANALYSIS-PLEASE RESUBMIT
[] ~ample tOO old. Sample not reGeived [] Onh
wlthlo 30 hours of collection
[] Oate di~rep&noy or form incomplete
(~l~,.~l~ J~ Item)
[] ~lty Ineufflclent for analysis ~.
{100 mi. minimum)
[] ~ In trannit
[] Not ~'~ ~ eo~telne~
FORT Wl)~H CITY HEALTH
DEPARTMENT LABI)RATI~RY
48010
[] Quantity (o~ g~at to permit a0itation
[] Other