215 SW EVERETT MALL WAY 2018-01-02 MF Import

? OSHS 13173(R"I) STATE ` ,.IINGTON ' DEPARTMENT OF SOCIAL AND HEALTH SERVICES( WATER BACTERIOLOGICAL ANALYSIS SAMPLE COLLECTION: HEAD INSTRUCTIONS ON BACK OF GOLDENROD COPY If instructions are not followed, sample will be rejected. DATE COLLECTED TIME COLLECTED I COUNTY NAME MONDAV YEAR / -i ) - /0TH 2L /6-? AM . ❑ PM S n_0 TYPE OF SYSTEM I IF PUBLIC SYSTEM, COMPLETE: PUBLIC CIRCLE CLASS ❑ FMINDIVIDUAL I.D. No.77 7 z 3 4 ,1�iGdfLET! (z)NDA QUIZ SPECIFIC LOCATION WHERE SAMPLE COLLECTED SYSTEM OWNER/MGR. NAME ANDTCLEPHONE NO. i Ile, kacaen tap scaUol. file station, ior,nlaln) -f - 1 14 Nvt-io A <C--¢.0 IC e SAMPLE COLLECTED BY: (Name) ; SOURCE TYPE (v\ ❑ SURFACE ❑ WELL ❑ SPRING 0 PURCHASED ❑ COMBINATION or OTHER SEND REPORT TO: (Print F� II Name. Address s and Zip Code) L, Z?w.�C) Cn�/orn 11 tt hA, WASHINGTON � TYPE OF SAMPLE tcl kOnlyors In IN, Column) 1. ❑ DRINKINGWATER ❑Chlorinated (Resitlual:_Total_Free) check treatment ❑ Filtered ❑ Untreated or Other 2. ❑ RAW SOURCE WATER 3. 0 NEW CONSTRUCTION or REPAIRS 4. ❑` OTHER (Specify) COMPLETE IF THIS SAMPLE IS A CHECK SAMPLE PREVIOUS LAD NO. PREVIOUS SAMPLE COLLECTION DATE - REMARKS: LABORATORY RESULTS (FOR LAB USE ONLY) MPN•COLIFORM STD PLATE COUNT SAMPLE NOT TESTED _/S waee pasnne /ml BECAUSE: MPN DILUTION TEST UNSUITABLE ❑ Sample Too Old /100 ml 1, ❑ Confluent Growth ❑ Not In Proper Container MFCOLIAORM (( l 2. ❑TNTC ❑ Insufficient Information -' /t00 ml Provided -Please Read FECAL COLIFORM3. El Excess Debris Instructions on Form ❑ MPN ❑ MF 4. ❑ ❑ /100 ml FOR` yDD,)IINKING WATER SAMPLES ONLY, THESE RESULTS ARE: ,SATISFACTORY ❑ UNSATISFACTORY SEE REVERSE SIDE OF GREEN COPY FOR EXPLANATION OF RESULTS LAB NO.. DATE, TIME RECEIVED- l i/ RECEIVED BY DATE REPORTED ( LABORATORY: REMARKS DSHS 13-173 M181)_�i STATE 9F'WAaHINGTON (s�, DEPARTMENT OF SOCIAL AND HEALTH SERVICES\ ,' WATER BACTERIOLOGICAL ANALYSIS SAMPLE COLLECTION: READ INSTRUCTIONS ON BACK OF GOLDENROD COPY If Instructions are not followed, sample will be rejected. DATE COLLECTED TIME COLLECTED COUNTY NAME MONTH DAY YEAR � * / CLAM ❑ PM TYPE OF SYSTEM IF PUBLIC SYSTEM, COMPLETE: ❑ PUBLIC CIRCLE CLASS I.D. No. ❑ INDIVIDUAL ') 2 3 4 Corms "My 1 Ieaidancel NAME OF SYSTEM Ili SPECIFIC LOCATION WHERE SAMPLE COLLECTED SYSTEM OWNER/MGR. NAME AND TELEPHONE NO. (le. 1,I1CI1Bn lap As scAaol. If farm fountain) Z L' )0uv vu 2 (�v �) Z -S SAMPLE COLLECTED By: (Name) ) SOURCETYPE �\ G ❑ SURFACE ❑ WELL ❑ SPRING )PURCHASED ❑ COMBINATION or OTHEFl SEND REPORT TO: (Print Full,Name, Address and Zip bade) _ OF SAMPLE Only One in this Column) 1. ❑ DRINKING WATER ❑ Chlorinated (Residual:_Total_Free) check treatment —► ❑ Filtered ❑ Untreated or Other 2. ❑ RAW SOURCE WATER 3. B NEW CONSTRUCTION or REPAIRS _4: ❑ OTHER (Specify) COMPLETE IF THIS SAMPLE IS A CHECK SAMPLE PREVIOUS LAB N0. PREVIOUS SAMPLE COLLECTION DATE REMARKS: LABORATORY RESULTS (FOR LAB USE ONLY). MPN-COLIFORM STD PLATE COUNT SAMPLE NOT TESTED _/5 maea"it". 41 MPNDILUTION TEST UNSUITABLE ❑ Sample Too Old /100 ml 1. ❑ Confluent Growth ❑ Not in Proper Container MF COLIFORM 2. ❑TNTC ❑ Provided -Please ed- Information / �00 mi Provided nPlease Read Instructions on Form FECAL COLIFORM 3. ❑ Excess Debris ❑ MPN ❑ MF 4 ❑ ❑ /100 m1 FOR DRINKING WATER SAMPLES ONLY, THESE RESULTS ARE: .❑ SATISFACTORY ❑ UNSATISFACTORY SEE REVERSE SIDE OF GREEN COPY FOR EXPLANATION OF RESULTS LAB NO. DATE. TIME RECEIVED- f RECEIVED BY J iQ)?[2c1 CY (_i /A/ DATE REPORTED LABORATORY: j REMARKS WATER SUPPLIER COPY ®,. WATER SUPPLIER COPY �a f