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STATE OF WASIIINGTON <br /> DEPARTMENT OF MEALiII <br /> WATER BACTERIOLOGICAL ANALYSIS <br /> �� � �„�ii�;�r,�� uir.oir,srnucro!�sur� nnckm i.mn�r�miur�� <br /> � If instmcllons ero nal lollowod, sample will be m�ocled. <br /> DATECOLLEC7ED 11ME COLLECTEO COUNTV NAME <br /> MONTN p�Y YEAR (� � / <br /> �G� J�J `� (�AM . ❑ PM ,//) c h v ��� S�j <br /> TVPE OF SYSTEM I PUBLIC SVSTEM,COMPLETE' <br /> [_�',Pueuc I.D. No. � � <br /> ❑ INDIVIDUAL � ' ' '� <br /> �I r�eM� <br /> � NAME OF SYSTEM• � <br /> ��� �.. S; � 3!� . D - �-� � <br /> $PfCIRf IOCA1i0N NfRESAMPIf f.Ullff.11115Y,ICMONRIEP/MfR HAMFA'.It��.l��=', , <br /> ��. �n e• ,.meo�.r,.,��u��, �/ <br /> b��cc., u�' ��� C L • U•� ' <br /> ��.,Q ..f �..Q_ ( )�>--;, rs•.� <br /> SAMPy�,O�LEC?ED BY:M�me� <br /> < o�.n�/ �,�`/� 7�''ro.� �,--- <br /> SOURCETVPE <br /> C� SUqFRCE ❑ WELL ❑ SPRINO �PURCHpSED ❑ COMBINATION <br /> or OTMER <br /> �5 � EPORT O:IPrint Full N�me.�U�n�e�nd 2iD Catel <br /> - O �`Yt f'7.L �:c I/�O�! S <br /> d L� C��. �a� <br /> �� �, a 7`f- 5'� , <br /> W�SNINGiON�( <br /> LYPE OF S�MPIE <br /> ICh[�on Y�^e in In�n[Murnnl <br /> 1. � ORINNINGWA7ER ❑ C�Ionneletl�ReelduaP_iatel_�r���•i <br /> c�etk Ileelmeni� � Flllefed <br /> ❑ U�Iree154 or Olher _. <br /> 2. � RAW SOURCE WATER <br /> 3. �NEW CONSTRUCTION or REPAIRS <br /> -0. ❑ OTNFR ISpeclly) <br /> --_-. __-.. --..-- �- ____-__--:.--:_'t. <br /> COMPLETE IF THIS SAMPLE IS A CHECK S�'dPl� <br /> 1'n1yl0U5IF9 NO <br /> PREVIOUS SAMPLF GOII FC11nN DATE__ . . . . . <br /> REMARNS ---- '— . - . . . <br /> _ _`�'� °s��; <br /> LABORATORY RESUITS�Fon ua us¢oniri <br /> 1APN�COLIFORM SiD Pl nT[COUNT SAMP�E NOT if',i f I� <br /> BECAusf <br /> �5��,�..i...���,. �mi <br /> MPN OIWTION TEST UNSUITABLE � Snmple Tn��ni��. <br /> �011 mi �, � Conlluent Growt� ❑ No1 In Prop���� � ��..�� .�� <br /> Mf�ORM <br /> 2. ❑ TNTC � h�sulliclantlntonn:�i����� <br /> �DO ml Provltle0—PIAa�c�b�,�; <br /> 10611UCIbl19 011 Forni <br /> f[CALCOLIFOPM 3. � EMceesDoDris <br /> ❑ M N ❑ MF 4 � � <br /> �na nn <br /> fORpRINNING WATEH SAMPLES ONLV,TMESE RESULTS RRE'. <br /> 10 GATISFACTORY ❑ UNSATISFACTORY <br /> i. . 1 � If -�IILLN GOPY FUR C;PL1NAllOt �� <br /> I.�O NO OAIF,tIME NELPVED-� RECEIVI i�l,� <br /> ����l.i�V �"`�� !y✓ � �'Ll� <br /> I�PIENEPOPiED L� OR�I RV <br /> i � <br /> IfM RNS <br /> �'.� �i 1 i�.�il.l'J I. 1 li <br />