Minyard Site-LR071128
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TA.RRANT COUNTY PUBLIC HEALTH
1101 S. Main St, Ft. Worth, TX 76104
USEPA Lab No. 01471 (817)321-4750
Date and Time Received Date end Time Re orted
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SAMPLE IDENT/F/CA TION
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Results
Seven digits (REQUIRED)
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Name If' In (!~/15/r"'[_ ho~/
Street Address i.J If S"D a, r; $11 D Jill
City, State Zip ~.IL ~ Le.. 1-1
Phone 17~ - J'jj." -~,-,_':jl
Downer/PWS DOperator
COUNTY
7:;;q/~G
PUBLIC WATER SYSTEM 10
PUBLIC WATER SYSTEM NAME
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Send
Sample
IX
7.10 ?J/
To:
To be checked by Sample Collector:
D
Other
SAMPLE SITE I COLLECTION DA TE and TIME
Date/TIme Collected: /I - ~ 7. .,),a' I Jr2.' ,;l ,r PP1 0 ca---'
Month Day Year Time of Del' am pm
Sample Site: B",//"/ /L."y , --~/ r,,< ~/Pr"/ /'~w./4'
(Addre:s or other descn. 'ption; not sa pie sire num";!!3
Sampler Name/Phone' ~ - 7 ,?."l- ~~j'- - ..)6-3
SYSTEM TYPE
[1;}FubliC
o Private/Individual
DOther_
SAMPLE TYPE
(Public Systems Only)
DOistribution DRaw: well #
[3construction DSpecial
o Repeat for sample #
OOlher:
WATER SOURCE
DGroundwater
(Well)
o Surface water
(Lake, River)
DISINFECTANT RESIDUAL (Mandatory)
(Sample should not be collected if no residual is present)
Number of samples collected on this date
mglL DFree Chlorine
OChloramine (Total Chlorine)
LAB ORA TORY REP~O Not Write BelOW)
Test Method Used: olilert PIA DColilert MPN
COLIFORM ORGANISMS:
Total Colifonn
~T Found
Escherichia col/
~Found DFound 1100ml
Du~tab'e for analysis (see below) Analyst Initials:
SAMPLE UNSUITABLE FOR ANAL YSISfThls unsuitable sample minI be replaced within 24 hrs,)
OSample loa old. Not received within 30 hours of collection OHeavy SILT I BACTERIA I TURBIDITY PRESENT (cirde)
OOuanlity insufficient lor analysis (100 mL required) Dsamp,e leaked In Irensit
DForm Incomplete I date discrepancy (CIRCLE errors) o Excessive Chlorine residual
OOlher reason DESCRIBE'
OMTF
OMembrane Filtration
DFound
/100ml
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Submit to TCEQJPubllc Drinking Water MC.155, PO BOX 13087, Austin, TX 787111 Fa. Positive to 512.239-3666
H-220 GPC.2190 Rev 06.04 COPIES. CUSTOMER, LABORATORY, TCEQ