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.� �....�.. ....�.. .... �.. pIM IG Uf IIMJ111 dY1Ur1 <br />DEPARTMENT OF3OCUL AND HEALTH SERVICES DEPARTMENT OF SOCIAi AND HEALTH SERVICES / <br />WATER BACTERIOLOGICAL ANALYSIS WATER BACTERIOLOGICAL ANALYSIS <br />SAMPLE COLLECTION: READ INSTRUCTIONS ON BACK OF GOLDENROD COPY SAMPLE COLLECTION: READ INSTRUCTIONS ON BACK OF GOLDENROD COPY <br />If Instructions are not followed, sample will be rejected. I I If instructions are not followed, sample will be rejected. <br />DATE COLLECTED <br />TIME COLLECTED <br />COUNTY NAME <br />MONTH DAY YEAR <br />I <br />a <br />❑ M ❑ PM <br />TYPE OF SYSTEM <br />IF PUBLIC SYSTEM, COMPLETE: <br />❑ PUBLIC <br />LD. NO. ' IRCLE CLASS t <br />❑ INDIVIDUAL <br />1 2 3 4 <br />I <br />bmn oNr t raalaenu) <br />NAME OF SYSTEM <br />SPECIFIC LOCATION WHERE SAMPLE COLLECTED <br />YSIFM ONNEIV INIGIL NAMEANO T. . <br />Pa. utt n aR a ¢soot ee )ytgrt 1 �.J J,. <br />p / <br />SAMPLE COLLECTED <br />DBBY: <br />p(Name) <br />cs <br />SOURCETYPE - - <br />ATION:� <br />❑ SURFACE ❑ WELL ❑ SPRING WPURCH SED ❑ COM <br />- or OTH R- <br />SEND REPORT TO: IPIinI <br />Name, Atldresa and 9p Coe el - - <br />' WASHINGTOh 0 / ' <br />TYPE OF SAMPLE <br />IGMCl n^II wN In IM) Cdamro <br />T. ❑ DRINKING WATER ❑ Chlorinated(ReclduaC_TOtat_Free) <br />check treatment Filtered - -. <br />❑ Untreated or Other <br />❑ AW SOURCE WATER - <br />. E1N CONSTRUCTION or REPAIR <br />. ❑lTHER (Specify) <br />&MPLFTE IF THIS SAMPLE IS A CHECK SAMPLE - <br />PREVIOUS LAB NO <br />PREVIOUS SAMPLE COLLECTION DATE . <br />REMARKS: <br />LABORATORY <br />RESULTS (FOR <br />LAB USE ONLY) . <br />MPN- COLIFORM <br />STD PLATE COUNT <br />SAMPLE NOT TESTED <br />�5 two Pouln <br />�Inl <br />BECAUSE . <br />❑Sample Too Old <br />MPN DILUTION <br />TEST UNSUITABLE. <br />/1OOmI <br />1. ❑ Confluent Growth <br />- 2 ❑ TNTC <br />❑ Not in Proper Container <br />Insufficient Information.,. <br />❑ <br />MF C LIFORM <br />�110 ml <br />Provided —Please Head - <br />- <br />3. ❑Excess Debris; �' - <br />Instructions on Form <br />FECAL•COLIFORM <br />❑ MPN, ❑ MF <br />4. ❑ '... <br />❑ <br />/1OD mI <br />FOR DRINKING WATER SAMPLES ONLY, THESE RESULTS ARE. - <br />[I SATISFACTORY'... - ❑ UNSATISFACTORY <br />SEE REVEIRSE SIDE OF GREEN COPY FOR EXPLANATION OF RESULTS <br />LAB NO. "' _ <br />WF� TIME RECEIVFO— / <br />ECEIVED BY <br />DATE REPORTED LABORATORY:. : <br />- fREMARKS <br />LABORATORY COPY <br />DAY <br />7 '.7— <br />_AM ❑ PM I <; tv,) <br />TYPEOFSYSTEM I IFPUBLIGSY5TEM,GUMeLLIC <br />❑ PUBLIC CIRCLE CLASS <br />❑ INDIVIDUAL I.D. No. O2 3 a <br />Inerrn aNY t n)gnncq <br />NAME OF SYSTEM' <br />NO. <br />I». ulcn.n lf_o-r.l.lwn rwm.lro I `� <br />Ij <br />SAMPLE COLLECTED BY: INa <br />SOURCETYPE `„6r <br />❑ SURFACE ❑ WELL ❑ SPRING PURCHASED COMBINATION. <br />.§❑ <br />or OTHER <br />SEND REPORT TO: IPrInIFe N m Add reasundbp Codel <br />WASHINGTON ' <br />TYPE OF SAMPLE <br />rCMc; mh ur+ln tma cdumnl <br />1. ❑' DRINKINGWATER ❑ Chlorinated(Residual:_Tolal_Free) <br />check treatment ---> ❑ Filtered ' <br />i ❑ Unheated'or Other <br />2 ❑ AW SOURCE WATER <br />EW CONSTRUCTION or REPAIRS <br />OTHER (Specify)_ <br />PLETE IF THIS SAMPLE IS A CHECK SAMPLE <br />PREVIOUS LAB NO <br />PREVIOUS SAMPLE COLLECTION DATE <br />REMARKS: - <br />LABORATORY RESULTS (FOR LAB USE ONLY) <br />MPN- COLIFORM <br />STD PLATE COUNT <br />SAMPLE NOTTESTED <br />,i: - <br />BECAUSE <br />❑ Sample Too Old <br />MPN DILUTION <br />. TEST UNSUITABLE'_ <br />XDO mil. <br />❑ Confluent Growth. <br />2. ❑ TNT C, <br />❑ Not in Proper Container <br />❑ Insufficient Information -.,. <br />MF COLLFORM <br />/1OD.mI <br />Provided —Please Read <br />3. [1 Excess Debris- <br />Instructions on Form <br />- <br />FECAL COLIFORM <br />❑ MPN ❑ MF <br />4. ❑ _ <br />-❑ <br />/I0n mI <br />FOR DRINKING WATER SAMPLES ONLY. THESE RESULTS ARE: . <br />bSATISFACTORY ---• -" ❑ UNSATISFACTORY <br />E REVERSE SIDE OF GREEN,COPY FORE%PLANATION OF RESULTS <br />LAB NO. <br />767rj34 <br />DATE,ZV E RECEIVED— _ .. / RECEIVED BY . _ <br />i-9-8(,C) <br />DATE REPORTED <br />UBOFMORY: <br />i� <br />REMARKS <br />LABORATORY COPY <br />