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%Nd <br />STATE OF W'.SHINGTON <br />DEPARTMENT OF UUIIAAND HEALTH SERVICE \, . <br />WATER BACTERIOLOGICAL ANALYSIS <br />SAMPLE COLLECTION: READ INSTRUCTIONS ON BACK OF GOLDENROD COPY <br />i It instructions are not followed, sambie will be rejected. <br />DATE COLLECTED TIME COLECTED I CU:INTY NAME <br />MONTH DAY ��l!YEAR L- - <br />IZ ZZ C&v ] AM ❑ PM I S <br />TYPE OF SYSTEM IF PUBLIC SYSTEM, COMPLETE: <br />®.PUBLIC I.D. No. CIRCLE cuss <br />•❑ INDIVIDUAL 2 3 4 <br />b.ne. UnlY 1 n.kanul <br />NAME OF SYSTEM <br />ClASG2c�L sfi�� CT� <br />SPECIFIC LOCATION WHERE SAMPLE COLLwrED SYSTEM DMJFA/MGR. NAME AND NE NO. <br />(K. HICMn en a..M . eu.Ylloq f..W-1 •y �/ <br />l� C E nYj R/1 L AA AEI tJ C�vlM1 / SAMPLE COLLECTED COLLECTED BY: (Name) n .- <br />I In <br />SOURCETYPE <br />❑ SURFACE ❑ WELL ❑ SPRING -PURCHASED ❑ COMBINATION <br />or OTHER <br />'EiENDREPORTTO�•.(Prmr Full Nat ddress and 2lp Cade) <br />lcM I only o 'a lw 10U.N <br />1. ❑ DRINKINGWATER ❑ Chlorinated (Residual:_Tot.l_Frel <br />check treatment ---* ❑ Filtered <br />00THE❑ untreated or Other <br />R <br />AW SOURCE WATEREW CONSTRUCTION or REPAIR^y (Specify) <br />COMPLETE IF THIS SAMPLE IS A CHECK SAMPLE <br />PREVIOUS LAD NO. <br />PREVIOUS SAMPLE COLLECTION DATE <br />REMARKS: <br />L. . <br />LABORATORY RESULTS (FOR LAD USE ONLY) {{ <br />C' MPN-COLIFORM STD PLATE COUNT i SAMPLE NOT TESTED <br />BECAUSE: <br />- <br />f'. MPN DILUTION TEST UNSUITABLE ❑ Sampie Too Oltl <br />�•,.: . 41Od ml . <br />j; �_ 1..❑ Confluent Growth ❑Not In Proper Contalne(,- <br />MF F1M 2 ❑ TNTC ❑ Insufficient Information <br />- <br />�00 ml _ Provided —Please Read r <br />Instructions on Form <br />ccrel enl IFnRM 3. ❑ Excess Debris <br />❑MPN.,❑MF <br />4. <br />El <br />I ❑ <br />- FOR DRINKING WATER SAMPLES ONLY, THESE RESULTS ARE: <br />• ❑�SATI FACTORY "y�lT <br />❑ UNSATISFACTORY <br />SjE REV RS`ESIDE OF <br />- EN COPY FOR EXPLANAtION OF RESULTS <br />LAO . <br />t'7 <br />D E, TIME DECEIVED— / <br />RECEIVED BY <br />I ,49 <br />' DATE REPORTED <br />LABORATORY: <br />R IA K <br />LABORATORY COPY <br />6. <br />STATE OF WA <br />SHINCTON <br />nr•S. l <br />DEPARTMENT OF SOdAL AND HEALTH SERVICES <br />WATER BACTERIOLOGICAL ANALYSIS <br />SAMPLE COLLECTION: READ INSTRUCTIONS ON BACK OF GOLDENROD COPY <br />It instructions are not followed, sample will be rejected. <br />DATE COLLECTED TIME COLLECTED I COUNTY NAME <br />MONTH DAY YEAR I r D `Z3 <br />[;77— Z Z 5(0 1 AAM ❑ PM '�•lJ <br />pATT!Y��PE OF SYSTEM IF PUBLIC SYSTEM, COMPLETE: <br />I�,YUBLIC CIRCLE CLASS <br />❑ INDIVIDUAL I.D. No. i 2 a A <br />1,.. .111 ¢.-Une.) <br />SPELIFMTOCAT10N WHERE SAMPLE COLLECTED SYSTEM DwNDVMGR. NAME ANDIEIELEPHME NO. <br />111(ll.n 4e 0 uMtl. III..w.. lwnu <br />�r;'•CA'.T�ALtUf�l� <br />SAMPLE COLLECTED BY; (Name)' <br />• SOURCE TYPE - . <br />❑ SURFACE ❑ WELL ❑ SPRING ,PURCHASED ❑ COMBINATION <br />or OTHER <br />SEND REPORT TO:( Fun Na tl evDtV7ZiP CPdS) 1� <br />� stir <br />. roc nv eeual F ` <br />ra: k only Una m Imt <br />i rr <br />1f 1. ❑. DRINKING WATER ❑ Chlorinated (Reslduab_7otal_Fme) <br />I ^., .c eck treatment •--> ❑ Filtered <br />❑ Untreated or Other <br />RIA SOURCE WATER ` <br />.((33q. W CONSTRUCTION or REPAIRS <br />OT <br />HER (Specify) <br />COMPLETE IF THIS SAMPLE IS A.CHE.YK SAMPLE <br />PREVIOUS LAB NO <br />PREVIOUS SAMPLE COLLECTION DATE <br />REMARKS: !t <br />I LABORATORY RESULTS (FOR LAB USE ONLY) <br />MPN -001JFORM STD PLATE COUfJ7 ! SAMPLE NOT TESTED <br />\ BECAUSE <br />MPN DILUTION - TEST UNSUITABLE ❑ Sample Too Old <br />/100 mI 1. ❑ Confident Growth ❑ Not In Proper Container,:. <br />, M/F (FORM 2 ElTNiC Insufficient Information `. <br />- / p �00 mI ❑ Provided —Please Read <br />Instructions on Form <br />FECAL COLIFORM 3. El Excess Debris <br />'❑ MPN ❑ MF 4. ❑ ❑ - <br />.' �00 m1 <br />FOR DRINKING WATER SAMPLES ONLY, THESE RESULTS ARE:' <br />❑ SATISFACTORY :7, ❑ UNSATISFACTORY <br />SEE REVERSE SIDE OF GREEWCOPY FOR EXPLANATION OF RESULTS <br />L_As No GATE TIME RECEIVED `• RECEIVED BY <br />1 <br />as <br />DATE REPCiRfED BORATORY: - <br />I REMARKS <br />) <br />LABORATORY COPY m, <br />i <br />