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WATER 5AGTEMV1 Do - i resu of Laboratories
Form No. G -19 (Rev. 12/91)
Date and Time Recd. Date
Sample No. ;t _$ r d.
S '1 not mark Move this line — PleaserMt Int pen or typewriter-
/ 1 a e
Water System I.D. No. NAME OF WATER SYS] t:"-
� 9 I L14
I ; � Ic�jl�
-r l
COUNTY
Submitter I.D. NO.
��� ��I rl e l�l I I � I �� ti5ltrl���l�l
SEND NAME
RESULTS
I�yljU}XI III : ���I I I I V I I
I III I I I I I I
STREET ADDRESS (P.O. Box)
TO: Lo , � L j No th I I I I I I I I TX
76 I (
I I I I
CITY
ZIP CODE
1
Date Time of C U IL
12
�tJ COLLECTED BY
Collection MONTH DAY YEAR TIME AM/PM
SAMPLE IS
TYPE OF SYSTEM (Public Systems Only)
WATER SOURCE
�/ •. �
�
Public E] Dairy. ❑ Distribution; F1 Raw
❑ River LT Cake
❑ Individual ❑ Bottled instruction ❑ Repeat
❑ Well Well Depth j
❑ School ❑ Special Chlorine Residual
Ownership or other information:
- LABORATORY REPORT (Do not write below)
Water of satisfactory bacteriological quality must be free from Colitorm organisms {
Coliform Organisms Not Found 41
/M Found
❑ Total coliform group
❑ Fecal c oMorm group
Repeat samples required T
❑ Unsuitable — See below
UNSUITABLE FOR ANALYSIS - PLEASE RESUBMIT
Quantity insufficient for analysis
oicf "f3ampPb received ❑ 100 ml. required)
within 30 hours of collection
❑ Date discrepancy or form incomplete ❑ Heavy (silt/bactedal growth) present,
(See encircled item) possibly compromising test results
❑ Leaked in transit
❑ Other