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Billing NAME
Reporting
Address CITY
TELEPHONE
TYPE OF D Public D Individual
SYSTEM: D Other
SAMPLE D Distribution D Special
IS:
D Repeal for sample #
D Recheck for sample #
DOther
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Construction
WATER DRiver D Lake DWell
SOURCE:
Well depth Chlorine Residual
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M.PN. Total Coliform 1100ML
(Colilert) E:CoIi. /100ML
Membrane F,ller/F_1 Coliform 1st Oil _ 1_ ml 2nd _, ~ - ml
Avg. _1_ ml
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UNSUITABLE FOR ANALYSIS: (This unsuitable sample must be replaced within 24 hours.) g
D Form Incomplete (see attached Item)
D Sample too old, not received within 30 hours of collection
D Excessive chlorine present in sample
D Unsuitable container
D Heavy, non-coliform bacteria/silt present. possibly obscuring and comPromising lest results
D Quantity 100 great to permit agitation
D Quantity insufficient for analysis (100 ml minimum)
D Other
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Analyzed by
Water of satisfactory quality should be free of Coliform Organisms
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