Hard 8 BBQ-LR060926fi
SAMPLE IDENTIFICATION
4 PtJ C. C WATER SYSTEM ID
PUBLIC WATER SYSTEM NAME
Send
Sample
Results
To:
Lab Specimen a
Name
r Bacteriology
I
Street Address
City, State Zip
Phone
Dateff ime Collected:
Sample Site:
SYSTEM TYPE
❑P hilt
Private /Individual
❑Other
To be checked by Sample Collector:
Total Coliform
INOT Found ❑Found
Escherlchla colt
[.NOT Found Found
Unsuitable for analysis (see below)
3e (REQUIRED)
TARRANT COUNTY PUBLIC HEALTH
1101 S. Main St., Ft. Worth, TX 76104
USEPA Lab No. 01471 (817)321 -4750
Date and Time Reported
Date and Time R slued
r
hT" �r
Q F.: f)
COUNTY
❑Owner/PWS ❑Operator
SAMPLE SITE COLLECTION DATE and TIME
cX: t>
Mdn Day Year
Time of Day
(Addre or description,' not sample site number)
Sampler Name/Phone: jr/ C "S 111 f
al
OM
W A R
SOURCE
SAMPLE TYPE E
(Public Systems Only)
['Distribution ❑Raw: well El Groundwater
B i6mistruction ❑$peeial e(I)
Repeat for sample Surface water
El Other: (Lake, River)
DISINFECTANT RESIDUAL (Mandatory) mg/L f Free Chlorine
(Sample should not be collected if no residual is present) ❑Chloramine (Total Chlor ne)
Number of samples collected on this date ni
LABORATORY REPORT (Do Not Write Below)
Test Method Used: Coliert P/A ❑Colilert MPN DMTF Membrane Filtration
COLIFORM ORGAN! MS:
/1
/100m1
Analyst Initials:
SAMPLE UNSUITABLE FOR ANALYSIS(rhis unsuitable sample must be replaced within 24 hrs.)
Semple too old. Not received within 30 hours of collection Heavy SILT BACTERIA TURBIDITY PRESENT (circle).
Quantit insufficient for analysis (100 mL. required) ❑Sample leaked in transit
EJ Form incomplete date discrepancy (CIRCLE errors) ❑Excessive Chlorine residual
❑Other reason: DESCRIBE
Submk to TCEO/Pubik Drinking Water MC-155, PO BOX 13087, Austin, TX 707111 Fax Positive to 612 239 -3111
H -220 GPC -2190 Rev.06 -04 COPIES: CUSTOMER, LABORATORY, TCEQ