HomeMy WebLinkAboutTHOMAS W SPERSTAD #1 Block 2 Lot 22---
i: tF:'i::'I ]:
I. (:l( :: I::l'l ] q I",1
I ,l~illiil'::l!_
F:Ot,;:'tll E:"," TI'Il!i: hlI._II'.,t]:(3:[Pr::iI.]:T'T' 131::' 1=II',,t(31.1ORF:I(]iI, i;.
:;i:: :i: I.,I ;t l,.l :[ I'.,l?f'Ftl.l.~ THE :E;'r'STI~Eh'I '[ I",1 FI(:::(:X31'zd3, f::II",ICE: 14 :( TH
I=IF' I: :'[. ]i C: I:::ll",l'] [:'ON 1'"1[!5 ]i IE 1:515!i;
'IIIE -':1'3 I':,t::[ ::ii.
LL
06-1220fa Rev. 1973
Lab No
DATE
ALA,.. DEPARTMENT OF HEALTH AND SOCIAL Si. JES
DIVISION OF PUBLIC HEALTH
INDIVIDUAL AND SEMI-PUBLIC
BACTERIOLOGICAL WATER ANALYSIS
OFFICE
NDIVIDUAL E]
NAME
SEMI-PUBLIC E CftLORINE RESIDUAL PPM
REPORT RESUETS TO
ADDRESS "
CITY .... ZIP CODE
ADDRESS
OF SOURCE
L~ Satisfaclory
E UnsaJJsfaclory
SANITARIAN'S REMARKS
COMPLETE THIS SECTION
ONLY IF WATER IS AN INDIVIDUAL SUPPLY
SAMPLE COLLECTED BY
Tot* -- U Wood L~ Collcrele u
PURPOSE OF EXAMINATION: Illness Suspected? [] Yes [] No
READ INSTRUCTIONS
ON
REVERSE SIDE
BEFORE
COLLECTING SAMPLE
o6.122o ~ BACTERIOLOGICAL WATER ANALYSIS RECORD
Rev. 1973
48 Hours
EMB AGAR