ST9902-LR060721
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City of~ewiSvi~e labora ory ;~(}I-(j Iktf
Water BacterioloeY '. 1.:. f/~t.. .rt4
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Name 'of Water Systemt C"aunty
Water System Iden~fica~an Number:
Jj,tsr. '
?~'ection PY(gtSr;
Billing
," J . :;of,./'
7r;;t?-<' .7' ~~/.;. (f!jiPM
(Ma/Day/Yr) >
NAME )r 1r~ ~ l R..,I'
STREET $JI (} IE ~c w hu-v 2 )--~9'f
CllY . 'rL/J.AI/ ~ TEXA~'''-'1'~JtJCQ
(Zip Code)
.'~".--
Reporting
Address
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TELEPHONE
TYPE OF o Public o Individual
SYSTEM: o Other "
,
o Oistributian LJ Special 0' ". .t...
SAMPLE Construcljan
IS:
WATER
SOURCE:
o Repeat far sample #
o Reche~ for sample #
o Other
OJ! 0 Lake
- Well depth .~
-:'~~ ....:...
DWell
Chlarine Residu81 ""-
!~.f
~
.f.. A~ent
: '01.
T atal ColifalTl)
E;Cqli.
/100~
/100ML
Membrane Filler~ecai ~~orm: 1~fDiI. _ ,_ ml 2nd _I ~ oml
~/ ---.-
" Avg, _1_ ml
,
'.\"-
..
~ ~
~;""-...
U~UITABLE FOR ANALYSIS: (This unsuitable sample must be replaced within 24 hours.)
BFann Incomplete (see attached item)
Sample too old. nat received within 30 hours of collectian
o Excessive chlarine present in sample
o Unsuitable container
o Heavy, nan-coliform bacteria/sin present. possibly 'obscuring and ccimpramising test results
o Quantity taa great ta pennit agitation
o Quantity insufficient far analysis (100 ml minimum)
o Other. .
$v
Analyzed by
Water 'of satisfactary quality shauld be free 'of Califann Organisms
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