Wynnpage North 1-LR050503
Citl! of Lewisville Laboratorl! J d, '/J)/ )
Water Bacteriolo& 11"11J.t;7
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, Name of Water System
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County
Water System Identification Number'
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Date Time ~'PM
(Mo/DaylYr)
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Pomt of Collection
Billing
NAME () T f'J- -; C A/)- -y
Reporting STREET / {. .~ fA/ ;/-/(/ " -'- ':- .J P.A~ -# :f<
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Address r J 'v /, r; ( 'I 7'
CITY - " ,v TEXAS ~
(ZIp Code)
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~ TYPE OF
r SYSTEM:
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TELEPHONE ( S) '7 // '), / ,/ ~ 6
o Public
o Other
o Individual
o Distribution
o Special
SAMPLE
IS:
Construction
o Repeat for sample #
o Recheck for sample #
o Other
DRiver
o Lake
DWell
WATER
SOURCE.
Well depth
Chlorine Residual ~
SULTS:
Total Coliform Present
E:Coh, Present
Total Coliform
E:Coli.
~
Absent-
/100ML
/100ML
t Membrane Filter/Fecal Coliform: 1sl011
I
_1-
ml 2nd _1_ ml
Avg, _1_ ml
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UNSUITABLE FOR ANALYSIS. (This unsuitable sample must be ~eplaced within 24 hours.)
o Form Incomplete (see attached item)
o Sample too old. not received within 30 hours of collection
o Excessive chlorine present in sample
o Unsuitable container
o Heavy, non-coliform bacteria/silt present, possibly obscuring and compromising test results
o Quantity too great to permit agitation
o Quantity insufficient for analysis (100 ml minimum)
o Other
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~
Analyzed by
Water of satisfactory quality should be free of Coliform Organisms
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