Villages of CC 4-LR 921130WAT 6CTMl0LOGY . Texas Department of Healtif
Form-40: 1;49 Rev. 12191
( ) Bureau of Laboratories
WATEFftACTE��OGT7«wF 'W I w
Form No. G `� Texas bepartment of Health
bale and Time Recd. 2 �°
�i S {aI
-19 (Rev. 12/91) r`' Bureau of La b ora torie s
I'laie and Time Recd. +'
y;
Sam Reported
Date- ._
Sample Reported
t mark above this li or. typewriter.
• 5
ark above this line � 4*t � betlWO typewriter.
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W _L_I I I �III�I �I I IW1I I IG oI) ° IPI�ILI ti
Water System I.D. No. NAME OF WATER SYSTEM
( I I I I I I I I I
Water System I.D. No. NAME OF WATER S1(PTEM
Jra COL
COUNTY
POINT OF COLLECTION COUNTY
Submitter I.D. No.
Submitter I.D. No.
SEND n E�'/�jlSl A1Irl�lilTiIoIM'I 1 1 1 1 1 1 1 I
SEND K A1 I 6ol 711' /IrI 1 I I I I I I I I
RESULTS 1 6 � 1 0 g j I 111 5( TS�oI SI I I I ( I I I I III I I I I I I
NAME
RESULTS N p () JC
I 1 I I I f�fi I p I't l I
STREET ADDRESS (P.O. Box)
TO:
I I I I I I I I I I I I I I I I
STREET ADDRESS (P.O. Box)
I
L�I�I I UL � �Illhl I I I I I I I - Tx 76 1 l ��
CITY
TO:
V II'' IUI ri ll I 1 Tx
- ZIP CODE
CITY ZIP CODE
" Time ti bid - I I
Collection t ' LLJ ®' 3 I I I
Date and
Time of L .�, o O ✓ ��/Q
MONTH DAY YEAR TIME AM/PM Ll EC
I I
COfieCtiOn r I I I
MONTH DAY YEAR TIME AMIPM COLLECTED BY
`5 TYPE OF SYSTEM (Public SAM ystems I S WATER SOURCE
ublic ❑ Dairy OQ Distdbution F] Raw . ❑ River L9 take
TYPE OF SYSTEM ; S, ,.AMPLE IS WATER SOURCE
- (Pu stems•Only)
< f
•❑
�'Pubc ❑Dairy ❑Distribution ❑Raw P-Lake
El River
El Individual El Bottled ;
❑ Co nstruction Repeat � Well. Well Depth
❑Individual ❑ Bottled [2-Construction ❑ Repeat ❑ Well Well Depth
[:1 School --E] Special Chlorine Residual
❑ School ❑ Special Chlorine Residual
Ownership or other information:
Ownership or other information: =•
LABORATORY REPORT (Do not write below)
Water of satisfactory eriological quality �st be free from Coliform organisms
Collform Organism Found
LABORATORY REPORT (Do not write below)
Water of satisfactory actedological uallty, ust be free from Coliform organisms
of
Coliform Organisms Not Found �N
Found
Found
Total coliform group
❑ Total coliform group
❑ Fecal ooliform group
❑Fecal coliform group
❑ Escherichia ooli
❑ Escherichia soli
❑ Repeat samples required
❑ Uosuftable ow —,Q" below
�� _ . -,,., '� : _
❑ RePeat samples required
❑ Unsuitable — See below
UNSUITABLE FOR ANALYSIS - PLEASE RESUBMIT
UNSUITABLE FOR ANALYSIS - PLEASE RESUBMIT
❑ Sample too`old. Sample not received ❑ Quantity insufficient for analysis
❑Same too old. Sample not received Quantity
within 30 hours of collection (100 mi. required)
❑ insufficient for analysis
within 30 hours of collection (100 mi. required)
❑ Date discrepancy or form incomplete ❑ Heavy (sift/bacterial growth) present,
(See encircled item) possibly compromising test results
❑ Date discrepancy or form incomplete growth) present,
❑Heavy (sil
❑ -
Leaked in transit
(See encircled item) possibly compromising test results
m i s
❑ Oilier
❑ Leaked in transit
❑ Other
T BACTERIOLOGY _ . I _ o ' Texas Department of HeaH*
Form o.'G -19 (Rev. 12/91). Bureau of Laboratories
4.P69 and Time IAec'd.
Sample No. _ _ Reported _
above this line ewriter.
I IYI 1 1016 ICIo JP A61L 4 I I I I I III -1 l
Water System I.D. No. NAME OF WATER SYSTEM
III! It U� 15 1 1 1 1 1 1
COLLEUICk4 COUNTY
Submitter I.D. No.
SEND IVI�1/�lflsl�l�l I ICI�Iti15111'"1�1�171 11 1 1 1 1 1 1
NAME
RESULTS I6 161001)1 s 0M 11 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1
STREET ADDRESS (P.O. Box) J
TO: I I ill I I�I
Ij1 I IWq I I TX � �(
CITY ZIP CODE
Time !a of
Collection MONTH DAY YEAR TIME AMIPM COLLECTED BY
TYPE OF SYSTEM ( SAMPLE IS WATER SOURCE
Public Systems Only)
�'ublic ❑ Dairy ❑ Distribution ❑ Raw * ❑ River [Lake
.z
❑ individual ❑ Bottled construction ❑ Repeat ❑ Well Well Depth
❑ School '❑ Special Chlorine Residual
Ownership or other informati
LABORATORY REPORT,(Do not write below)
Water of satisfactory bacteriological uality Must be free from Col'rform organisms
Colitorm Organtams �khlot Found
❑ Found
❑ Total coliform group
❑ Fecal coliform group
❑ Escherlchfa colt
❑ Repeat samples required
lJas�itable — See bejSaw .. _
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 (silVbacterial growth) present,
(See encircled item) possibly compromising test results
❑ Leaked in transit
!` ❑ Other