Villages of CC P4-LR 930519 Form No. ~19 (Rev. 1~91) :, / ~ ~ B~reau of L~o~es
RE~ NAME
~ kk STRE~ADDRESS (P.O. BOX)
~ D~e and
~. ~PE OF 5YS~M SAMPLE IS WATER ~URCE
~ (Public Sy~ems Only)
,~ublic ~i~ ~ Distrib~on ~ Raw ~ River ~ake
~ Indi~du~ ~ Boffi~ ~Cons~ucfion ~ Re,at ~ Welt Well Dep~
~ Sch~l ~ Special Chlorine Residual
LABO~TORY REPORT (Do not write ~1~)
~: Wa~ of ~tis~.~iol~ic~ quali~ must ~ flee from ~l~0rm o~anisms
Coliform Organisms. ~ ~No~F0und
~ ~1 col~orm gm~p
~ Re.at samples requked
~ Unsuit~le ~ 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 ~tem)
[] Leaked in transit
[:~ Other ; ~ -
[] Quantity insufficient for analysis
(100 mi. required)
[] Heavy (silt/bacterial grow~) present,
possibly compromising test results
WATER BACTERIOLOGY ~-~'~'~ ~'<
Form No. G-19 (Rev. 12/91) . Bureau of Laboratories
Date and~meRec'd. ' ~ ' D~e ~ /
~ ~t ~ ~e ~is line %~fe~e' Pd~t~b ~ ~ ~ ~
Warn, S.em I.D. No. NAME OF WATER 8YS~M
POINT OF COLLECTI~ COU~
Subm~erl.e. No. [ I I I I I I I ~
NAME
STRE~ ADDRESS (P.O. Box)
ITx
CI~ ZIP ~DE
Coll~ection~ Mo~m-~ DAY YEAR TIME AM/PM COLLECTED BY
"-~,'~E OF SYSTEM SAMPLE IS
(Public Systems Only) WATER SOURCE
,k~l~lic [] Dairy [] DistribCaan [] Raw [] River [~ake
[] I~,vidual [] Bottled ~'"Construction [] Repeat [] Well Well Depth
[] Sch~x~l [] Special Chlodne Residual
Ownersl~ip Or other information:
LABORATORY REPORT (Do not ~m'lt a below)
Water of satisfactory ~ctedologicaJ quality must be frae from Coliform Organisms
Coliform Organisms J~3LNot Found
~ [] Found -
[] To~at qotfform group
~'~' · [] F~cal coliform grobp
[] Escherichla coil
' ~ [] 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 encimled item)
[] Leaked in transit
[] Other
[] Quantity insufficient for ~
(100 mi. required)
[] Heavy (alit/bacterial growth) present,
possibly compromising test results