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STATE OF WASHINGTON <br />DEPARTMENT OF HEALTH <br />WATER BACTERIOLOGICAL ANAL' <br />SAMPLE COLLECTION: READ INSTRUCTIONS ON BACK OF GU,DE <br />It Instructions are not followed, sample will be rejecle! <br />CATECOLLECTED TIMECOLLECTED COUNTYNAME i JMgNTH DAY YEAR I C2 LiLf SnohomiSr <br />TYPE OF SYSTEM IF PUBLIC SYSTEM, COMPLETE: <br />6cI PUBLIC 2 1 4 1 0 5 0 L <br />❑ INDIVIDUAL <br />1"+rvn °°M ] resNeael <br />NAME OF SYSTEM <br />City of Everett, Public Works Dept <br />GROUP <br />B <br />SPECIFIC LOCATION WHERE SAMPLE COLLECTED TELEPHONE NO. <br />oil Fl-.tip)( c" ;;,:I:, c.' DAY (425) 257-8824 <br />EVENING (425) 257-8821 <br />SAMPLE COLLECTED BY:(Name) SYSTEM OWNERIMGR:(Name) <br />A f -, r John McClellan <br />SOURCETYPE ❑ GROUNDWATER UNDER SURFACE INFLUENCE <br />® SURFACE ❑ WELLor ❑ SPRING E] INTERTIEPURCHASEDIX ❑ OTHNATION <br />SEND REPORT TO: )Print Ful Name, Address and Zq Code) <br />F.nvirnnmental Quality c/o Aaron Crotts <br />3200 Cedar Street <br />TYPE OF SAMPLE (check o*one in Ws column) <br />1 <br />D,. <br />❑ <br />ROUTINE © Chlorinated (Residual: <br />'_ <br />Total—Tre.e), <br />DRINKINGWATER Filtered <br />" <br />chedrImalmenl —4 ❑ Untreated or Other <br />❑ <br />REPEATSAMPLE <br />Reviouscdifampresence Labs <br />Date COAeded —J I <br />❑ <br />RAWSOURCEWATER SourceI 0 1 <br />❑ Total Cdilorm <br />b <br />NEW CONSTRUCTION or REPAIRS <br />❑ Fecal CoUorm <br />❑ <br />OTHER(Spedly) <br />WARKS: J ! _ l; 11 <br />l <br />(LAB USE ONLY) DRINKING WATER RESULTS <br />❑ UNSATISFACTORY, Colilorres present <br />; LJ SATISFACTORY <br />C0111T.ms absent <br />REPEAT ❑ E. Coll resent ❑ E. Coll absent <br />SAMPLES p <br />REQUIRED ❑ Fecal present ❑ Fecal absent <br />OTHER LABORATORY RESULTS <br />TOTALCOLIFORM I100ml E. COU IIWind <br />FECAL COUFORM 110(N PLATECOL T Iml <br />ANOTHER SAMPLE REQUIRED <br />SAMPLE NOT TESTED BECAUSE: TEST UNSUITABLE BECAUSE: <br />❑ Sample too old ❑ Confluent growth <br />❑ Wrong container ❑ TNTC <br />❑ Incomplete tone ❑ Turbid culture <br />❑ ❑ Excess debris <br />SEE REVERSE SIDE OF GREEN COPY FOR EXPLANATION OF RESULTS <br />LAB NO(7 DIGITS) <br />DATE, TIME RECEIVED <br />RECEIVED BY <br />DATER DRIED <br />LABORATORY:• <br />•� CITY OF EVERETT <br />L <br />` <br />" ENVIRONMENTAL LABORATORY <br />RswRu <br />3200 CEDAR STREET <br />WM l]fp] IRry4Ttl]I <br />EVERETT, WA 96201 � <br />STATE OF WASHINGTON P W (06(-fif <br />DEPARTMENT OF HEALTH <br />WATER BACTERIOLOGICAL ANALYSIS <br />T LE/COOLLECRON: READ INSTRUCTIONS ON BACK OF GOLDENROD COPY <br />/ )II Instructions are not followed, sample will be rejected. <br />h <br />�11pT LECTED TIME COLLECTED COUNTY NAME <br />1 �t .— <br />ONTM Y YEAR r �% Snohomish <br />? 3 �Il: ❑ AM ❑ PM <br />2141015101LI�A`UM <br />NAME OF SYSTEM <br />City of Everett, Public Works Dept <br />SPECIFIC LOCATION WHERE SAMPLE COLLECTED TELEPHONENO. <br />rG SC ram. ti°n u., C,),' dve. vf"j DAY (425) <br />tn� <br />.......41- llcl lk s,Vul t J EVENING 142. <br />SAMPLE COLLECTED BY., (Name) - SYSTEM OWNERVGR.:(Name) <br />A C t - S I John McClellan <br />SOURCETYPE ❑ GROUNDWATER UNDER SURFACE INFLUENCE <br />® SURFACE ❑ WELLM TIE WELL FIELD ❑ SPRING ElMERHASEDor ❑ oOBINATION <br />THER <br />SEND REPORTTO: (Pnnl FuA Name, Address and LD Code) <br />Environmental duality c/n Aaron Crotts <br />3200 Cedar Street <br />❑ ROUTINE <br />DRINKING WATER <br />check bealmenl ,4 <br />❑ REPEATSAMPLE <br />Prevbus cobfortn presence Lab a <br />Date Collected <br />Q Chlonnaled(Residual: <br />© FAIe]ed <br />❑ Untreated or Other_ <br />❑ P: WSOURCEWATER Sources 0 1 ❑ Total Caliform <br />[>� NEW C(al,".TRUCTION or REPAIRS ❑ Fecal CoAlorm <br />❑ OTHER(Spedy) <br />(LAB USE ONLY) DRINKING WATER RESULTS <br />❑ UNSATISFACTORY, Colilonns present <br />�` SATISFACTORY <br />Colitorms absent <br />REPEAT ❑ E. Coll present ❑ E. Colt absent <br />SAMPLES <br />REQUIRED ❑ Fecal present ❑ Fecalabsenl <br />OTHER LABORATORY RESULTS <br />TOTAL COLIFORM /1DDml E.COU 1100m1 <br />FECAL COLIFORM /1DON PLATECOUNT /N <br />ANOTHER SAMPLE REQUIRED <br />SAMPLE NOT TESTED BECAUSE: TEST UNSUITABLE BECAUSE <br />❑ Sample loo old ❑ confluent growth <br />❑ Wrong container ❑ TNTC <br />❑ Incomplete lone ❑ Turbid culture <br />❑ ❑ Excess debris <br />SEE REVERSE SIDE OF GREEN COPY FOR EXPLANATION OF RESULTS <br />LAB NO 7DIGITS) DATE TIME RECEIVED RECEIVEDBY <br />s <br />DATE RED ArTED j eoAArDRY: CITY OF EVERETT <br />ENVIRONMENTAL LABORAT Y, / <br />32DO CEDAR STREET Z w„wsa]tRcvv]omt <br />EVERETT, WA 98201 ,� <br />