Valley R Baptist-LR 940414 Date and ~mA Recd. Date
. _. .... 1
~ t~. b t O° n°tmad~'.~';'-~-:~;hi~tiaa~- Please .Pd. nt!w~ilba~aoiNpena~typewrfler. '
WAler System I.O, No_ NAME OF WATER SYSTEM
~aT ~ COL, ~-CTn~ I
~n~..rr., No_ I I I Il I I I I
~ :STREET ADDRESS
CiTY ZiP ~DE
'DAte afld
TYPE OF SYSTEM SAMPLE IS
&a uMic Syslems Only) WATER SOURCE
,.J~Public [] Dairy [] Distribution [] Raw, '-"O'River ~ LAke
[] Imfividual [] Bollled [.~ Co~struclien [] Repeat [] Wail Well Depth
[] School [] Specla[ CNorlne Residual
Ownership or elher informalion:
LABORATORY REPORT (Do AOI wrlle below1
Water of satisfactory be, eta,rio/ag(cai qual(ty must be free from Coliform organisms
Coliform O~Banlsms '~lot Found
[] Found
[] Total coliIo~m group
[] Fecal coJlform group
,, [] Repeat samples required
~ [] Unsuitable -- See bAk~w
UNSUITASLE FOR ANALYSI:5 - PLEASE RESUBMIT
E] Sample too old. Senile not mcelved
wilh~ 30 hours ot collection
~ Dare ~ac~epaa,oy or form Incon~lete
(See encircled item)
[] Le~ed In lransJt
[] O~har
[] Quantily insulitclanl for analyAis
(~ 00 mi. required)
[] Heavy (s~bactedal gro.~h) presell,
possiMy compron~sing test results
Date And ' ~ ~
JdO~ITH ~y YEAR TIME CO~ECIE~
TYPE ~ SYSTEM S~LE 18
~u~ 8ys~s ~) WATER SOURCE
~ Pu~ ~ Dai~ ~ ~ DiMn~ti~ ~ Raw ~ ~[ver ~ LAke
~ship or ~her i~ormaeon:
"LABORATORY REPORT (Oe not wrilo below)
Water of sAIIs[actmyLl~l~teriolo~jFc~lr qnalrly most be free from Cofiforl ~ olgaeismA
Col Iorm O~ganlanm /,~No~ Found
[] Found
[] Total oolffal'rs gra'~blp
[] Repeat samplAa requbed
[] UAel.,i~ble -- See below
[] SAmple ted old. Sample ~ received
· wlthkq 30 hours M collection'
[] Date o"mcrepAncy or Iorm Jncomplele
(See anti,clad Item)
[] Le,~ed in transit
UNSUITABLE FOR ANALYSIS - PLEASE'RESUBMIT '
[] QuaArJlyinsuffrct~t for anarys/a ~'~
(100 mt. required)
[] Heavy (alii/bacterial grow~)
,ptmsib~ compromising test I'e~JlIs
DATE
04×19
TIME
13:11
MESSAGE
TX-TIME
00'00"
CONF I RMAT I ON
DATE: 04xl 9?94
ID:
DISTANT STATION ID MODE
918176404774 G3-S
PAGES
000
TIME:13:ll
RESULT
BUSY