Villages of CC 4-LR 921203Form Nib. G (Rev.12/91
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Bureau of Laboratories
DateL&W TirA R c d j 9 9 ji f Reported
Sample No. ( J
Do not mark above this line — Please 0 61 AK101polil peF br
I�If I�I�I I I�IrI I ICIvIPl�lcill�-i I I I I I I I I I 1 1
Water System I.D. No. NAME OF WATER SYSTEid
� " It I o e I I I I I I I I I I I I I 1 1 I A v e I/ SI 1 1 1 1 1 1
POINT OF COLLECTION COUNTY
Submitter I.D. No.
SEND i S 1 IMI 1 161,09 S7 1
RESULTS jfj'QI I
STREET ADDRESS (P.O. Box)
TO: V1 1a1till ! T X
CITY ZIP CODE
' pate and FY :
/ 3 � m l�
Z1oIIeCtiOn MONTH DAY YEAR TIME AMIPM COLLECTED BY
TYPE OF SYSTEM SAMPLE IS WATER SOURCE
(Public Systems Only)
E2-9ubiic ❑ Dairy ❑ Distribution ❑ Raw ❑ River ❑ Lake
❑ Individual ❑ Bottled �' nstruction ❑ Repeat ❑ Well Well Depth
❑ School ❑ Special Chlorine Residual
O wner s hip o r ot h e r inf
ATE OL'bGY
Form � . G -1 (Aev.12t91
Dat@41hd Time Recd.
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Date and ��P
Time of LA 0 r r Z '} /
Collection MONTH DAY YEAR TIME AMIPM COLLECTED BY
this line — Pleappy beNpotnt
lciwl I I 10[F1 I (loll �1 � I I I I I I I I I
Water System I.D. No. NAME OF WATER SYSTEM 00
is I I 'I I I I 1 I I��h'(L
PONT OF COLLECTION COUNTY
Submitter I.D. No.
SEND A V 1 if eel I I (1 �Ir lu l L1 1 1 1 1 1 1 1 1
NAME
RESULTS �"I I if I0VCI I/ IS181 1 11 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1
STREET ADDRESS (P.O. Box)
Ir 1 l' 11 W ce 7141 1 1 1 1 1 1 1 TX 7 1( LWJ
CITY ZIP CODE
TYPE OF SYSTEM
Public ❑ Dairy
❑ Individual ❑ Bottled
Texas Department of Health
Bureau of Laboratories
SAMPLE IS WATER SOURCE
(Public Systems Only)
❑ Distribution ❑ Raw ❑ River ❑ Lake
(Construction ❑ Repeat ® Well Well Depth
❑ School ❑ Special Chlorine Residual
Ownership or other information:
LABORATORY REPORT (Do not write below)
Water of satisfactory Weriological quality must be free from Coliform organisms
Coliform Organisms &NotFound
���❑
Found
❑ Total colifo rm group
,.. - _ _. _ ---- s - "--❑ FeeaF�ebferr+Fgesaupf` - _.._....__ "..,_..Rye._.
❑ Escherichia Cbf
❑ Repeat samples required
❑ Unsuitable — See below
LABORATORY REPORT (Do not write below)
Water of satisfactory bacteriological quality must be free from Coliform organisms
Coliform Organisms lot Found
/ ❑Found
❑ Total coliform group
❑ Fecal coliform group
❑ Repeat samples`Taquired
❑ Unsuitable — See below
UNSUITABLE FOR ANALYSIS – PLI
❑ Sample too old. Sample not received
within 30 hours of collection
❑ Date discrepancy or form incomplete
(See encircled item)
❑ Leaked in transit
❑ Other
❑ Quantity insufficient for analysis
(100 ml. required)
❑ Heavy (siWbacterial growth) present,
possibly compromising test results
UNSUIT E FOR ANALYSIS – PLEASE RESUBMIT
❑ Sample d. Sample not received ❑ Quantity insufficient for analysis
within 30 rs of collection (100 ml. required)
❑ Date di or form incomplete ❑ Heavy (siWbacterial growth) present,
(See encihded hem) possibly compromising test results
❑ Leaked in transit
❑ Other