Stonemeade-LR 930303I No. G -19 (Rev. 12/91) Bureau of Laboratories
Date and Time Recd. Date
Lam ple No..
Reported
Do not mark above this line — Please print with ballpoint pen or typewriter.
t f lt-�I - I I (f d k't 1 1 1 1 1 E
Water System I.D. No. NAME OF WATEN SYSTEM
7 r ,, L t I I4 GJ /1f4r�1 I I
I k I�t� I c i,t kl K l�ra,l(11 114' -�
POINT OF COLLECTION COUNTY
Submitter I.D. No.
r7
SEND 1q I C14 1 1 1a ( I �,I i f "rd f �1s11'I f I I I I
NAME
RESULTS I' I t I I I
STREET ADDRESS (P.O. Box)
Tx I I I I I I
CITY ZIP CODE
Date and
Time ti � � LI E.� M
Collection MONTH DAY YEAR TIME AM /PM COLLECTED BY
TYPE OF SYSTEM SAMPLE IS WATER SOURCE
(Public Systems Only)
❑ Public ❑ Dairy ❑ Distribution ❑ Raw ❑ River ❑ Lake
❑ Individual ❑ Bottled ❑'Construction ❑ Repeat ❑ Well Well Depth___
❑ School ❑ Special Chlorine Residual _
Ownership or other information:
LABORATORY REPORT (Do not write below)
Water of satisfactory bacteriological quality mus be free from Coliform organisms
Coliform Organisms of Found i
❑ Found F.
❑ Total coliform group
❑ Fecal coliform group
❑ Escherichia Cali
❑ Repeat samples required
❑ Unsuitable — See below
UNJUI I ABLE FOR ANALYSIS – PLEASE RESUBMIT
❑ Sample too old. Sample not received ❑ Quantity insufficient for analysis
within 30 hours of collection (100 ml. required)
❑ Date discrepancy or form incomplete ❑ Heavy (silt/bacterial growth) present,
(See encircled item) possibly compromising test results
❑ Leaked in transit
❑ Other
VVH I r-n DA%., i G I i exaa LiVIAM BUprq Ut ngiLUI
Form No. G -19 (Rev. 12/91) Bureau of Laboratories
Date and Time Rec'pl. Date h,
--ttSS • ' �. .
S" "o4 3 C Reported
o
Do not mark above this line — Please print with ballpoint pen or typewriter.
y '^� 1 �
Water System I.D. NO. I -H Qti n Mrw: i WAT k � n 1 1 A l 1 1
I CAiribL'hl t, j,J If I A I I I I�IPf+l�f�� I I I
POINT OF COLLECTION COUNTY
Submitter I.D. No.
SEND I lei 164- 1 y1y1U1'1P I bY,lsi��f 44�1�I�Y11 I I I I
NAME
RESULTS I l l /I('I I F I rX1� I I I I I I I I III 1 1 1 1 1 1
STREET ADDRESS (P.O. Box) I ,
TO: I I
� , 7�,�1 cl� I�°t I Its I I I 1 1 I .I'Y�. LYE L1_l�J
C ITY ZIP CODE
'., - �
Date and 3 �:� � L�
Time of
Collection MONTH DAY YEAR TIME AWPM COLLECTED BY
TYPE OF SYSTEM SAMPLE IS WATER SOURCE
(Public Systems Only)
'Public ❑ Dairy ❑ Distribution ❑ Raw []River ❑ Lake
❑ Individual ❑ Bottled 'Construction ❑ Repeat ❑ Well Well Depth_
❑ School ❑ Special Chlorine Residual
Ownership or other information:
LABORATORY REPORT (Do not write below)
Water of satisfactory bacteriological quality must be free from Coliform organisms
Coliform Organisms of Found
❑ Found
❑ Total coliform group
❑ Fecal coliform group
❑ Escherichia soli
❑ 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 encircled item)
❑ Quantity insufficient for analysis
(100 ml. required)
❑ Heavy (silt/bacterial growth) present,
possibly compromising test results
❑ Leaked in transit
❑ Other
��.��.... exas veNannielu ui neaun
Form No. G -19 (Rev. 12/91) Bureau of Laboratories
Date and Time Bec�f' . Date
Sample IyQ. Reported
Do n ot mark above this line — Please print with ballpoint pen or typewriter.
I �''I +I "I ' 1
Water System I.D. No. NAME OF WATER SYSTEM
11pt I�Vi i6 - dji,T" j 1T1=r�- ITT I I I I� l I I I
POINT OF COLLECTION COUNTY
Submitter I.D. No.
SEND I* 14tf I�X�3 f fSl IrA'tl�l�l I I I I I I I I I I I I I
NAME
RESULTS
STREET ADDRESS (P.O. Box)
TO:
Tx_.- V I I I
CITY ZIP CODE
Date and
Time of ti �,':, � Lj ���, ,1 ITX, F--
C0112CtlOn MONTH DAY YEAR TIME AM/PM COLLECTED BY
TYPE OF SYSTEM SAMPLE IS WATER SOURCE
(Public Systems Only)
Public ❑ Dairy ❑ Distribution ❑ Raw ❑ River ❑ Lake
❑ Individual ❑ Bottled 0 e6nstruction ❑ Repeat ❑ Well Well Depth
❑ School ❑ Special Chlorine Residual
Ownership or other information:
LABORATORY REPORT (Do not write below)
Water of satisfactory bacteriological quality ust be free from Coliform organisms
Coliform Organisms ot Found, �j�
❑ Found
❑ Total coliform group
❑ Fecal coliform group
❑ Escherichia coli
❑ Repeat samples required
❑ Unsuitable — See below
UNSUITABLE FOR ANALYSIS – PLEASE RESUBMIT
❑ Sample too old. Sample not received ❑ Quantity insufficient for analysis
within 30 hours of collection (100 ml. required)
❑ Date discrepancy or form incomplete ❑ Heavy (silt/bacterial growth) present,
(See encircled item) possibly compromising test results
❑ Leaked in transit
❑ Other