|
f1e,..f WeddnPl.n .
<br />D•Mn.ossm el S.del end Neelth SOee
<br />Heel'h Snvkn 01•Mert B 17•9
<br />Wth Tower, $"Ms. W.aMr,fl.s, 98704
<br />WATER BACTERIOLOGICAL ANALYSIS
<br />e READ INSTRUCTIONS ON BACK OF GOLDENROD COPY
<br />IF INSTRUCTIONS ARE NOT PROPERLY FOLLOVH I
<br />SAMPLE WILL BE REJECTED.
<br />DATECOLECTED us -a«
<br />Mor1T Dey Ya
<br />%✓ �-J, aJ
<br />T1Me err UAT u« L«.nv.,
<br />�•/,nI I ou 1133$ I 1341 •4u«
<br />-S--n--o---
<br />O OPM2 4COLLECTED AM1 ..
<br />O/!-Lt�IEE Sr .CIRCL2 'L,
<br />CIA,, L ll, EJ IeLQ
<br />Irk -
<br />SYSTEM AODz 0 J C t I C .
<br />LOCATWNWNESSSAM owmA CSOLLSCNDIJfy� wheel, f11,a1., ete.l
<br />COIL[Cj�,ATt INa/,el �L e V MR P N .
<br />TYPE ter« I•�MaCMIn w2.0 C a3O MRIWdw,ee
<br />sSYSTEMM
<br />SEND REPORT TO: (Print FuH Nome,'Addrws and Zip C*Je1
<br />C J9'CL i+` . WASHINGTON -�
<br />SOURCE TYPE t», - -- •' Combnlauon
<br />10 S rroo; 20 well; 30 Spt'ng; 40 Purd,014d; 9,VR or Other
<br />TYPE OF SAMPLE 1pe1 (CHECK ONE ONLVI New Swimm+n0 Swlmmirq
<br />1 O Drmklrp Water 20 WoerRo- 3ftsL Moin.4O Pool SO Bach
<br />Sanitary Shellfish Other0 Survey 70 Seoweter 80 Study 90 Ism.fyl
<br />IS THIS SAMPLE A FOLLOW-UP TO A uu
<br />PREVIOUS. NON -CONFORMING SAMPLE? - 10 Yes 0,19 No
<br />IF YES, GIVE PREVIOUS LAB. NO
<br />SYSTEM TREATMENT tChehaonI Io0.r Drinking War« SomPles'
<br />'" � 4 0 Floaidolion;
<br />I Q None 2 �i Chtorirwuon; 3 O Filtro'ian;
<br />9 Q Other(Specify'
<br />REMARKS: / Z_
<br />L
<br />LABORATORY RESULTS
<br />SEE REVERSE SIDE OF PINK COPY FOR INTERPRETATIONS
<br />A. COLIFORMS PER 100.1 C. FECAL COU FORM ❑ RESUBMIT SAMPLE
<br />5 TUBE MPN TEST Lem / I00as
<br />Test Unsuitable Because:
<br />1MPN no11. ❑ Confluent Growth
<br />L
<br />• ors -e2.2. - E - x. ❑TNTC
<br />taraol _+1/5-2.2 MF /100ml 3.❑EaC-1Oebrts
<br />+ 3/5-9.2 ❑ RESUBMIT SAMPLE n,-73,
<br />4/5 - Ie Sample Rejected Because: IChec4 One WMore'
<br />+ 5/5 - s16 1. ❑ Sample Too Old
<br />MF
<br />%) / I00m) 2. ❑ Fee Not Provided
<br />I.,..el •� . � E _, 3. C) Sample Received Too Late In Week
<br />MPN DILN. TESTS 4. ❑ Insufficient Info, rcllon Provided.
<br />/100 ml Please Read Instructions On Form.
<br />E _ 5. ❑ Not In Proper Container
<br />B. STD. PLATE COUNT 6. ❑ Leaked Out
<br />7. ❑ Other (Specify)
<br />/ml
<br />aaa«_ • - E_
<br />REMARKSso
<br />f •� `
<br />DATE &TIME DATE /l
<br />RECEIVED' '--f'->J' COMPLETED -
<br />WATER SUPPLIER COPY
<br />i
<br />COeMShort*
<br />of,P1M
<br />.4Tel esdHer.k..
<br />CH.W,h Services pvlYo. 11 Ir.1
<br />$,do% T.wer, Swhle, Weibi"Vess 92104
<br />WATER BACTERIOLOGICAL ANALYSIS
<br />READ INSTRUCTIONS ON BACK OF GOLDENROD COPY
<br />IF INSTRUCTIONS ARE NOT PROPERLY FOLLOW �J / J
<br />SAMPLE WILL BE REJECTED, (*'���a
<br />DATECOLLECTED ue-a anwrc>,rn: -
<br />Mene, laor Ya
<br />/o a3 ��
<br />i1MEOFDAV te« I.D.NO.IPgWie SYNerllsl COUNTY NA
<br />COLLECTED XAM 1 1311 un Ian wI 1 LL
<br />OPM2 S/'7 0-!
<br />NAME A EST ORCLECLA55
<br />iT ! 1234
<br />srsTEMAOWP/fS' 2 o u �r f a r S F
<br />TYPE Of a«rpMumcipal CaMn,urYlr or 2 O 'con' or7 O Ralder,ee
<br />rw
<br />SYSTEM
<br />SEND REPORT TO: Wrint Full Noma, Address and Zip Code,,
<br />e,*3 Ot EJosCr
<br />3 ZOO CP t�Or
<br />J OIC P N' _, WASHINGTON
<br />SOURCETYPE :an Camb.rauon
<br />10 Surface; 20 Well: 30 SM,,,T 40 Purchased; gig at 011wr
<br />TYPE OF SAMPLE "" (CHECK ONE ONLY' New Swimming Swlmming
<br />10 Dtinkmg Woter 20 R"w 3) Main 4 0 fool 50 Beach
<br />Sanitary er Shellfish Other
<br />6O Sulvey 70 Seawater 80 Study 9 0 l5psafyl
<br />IS THISSAMPLE A FOLLOW-UP TO 131I
<br />PREVIOUS. NON CONFORMING SAMPLE? I O Yes 0A% No
<br />IF YES. GIVE PREVIOUS LAB. NO
<br />,eel SYSTEM TREATMENT IChedt only for Drinking Winer SOMPINI
<br />10 None. 2)4 Chwinatlen; 3 0 F11tro„on; 4 0 Fluoridation;
<br />9 O Other IS,,eafy' -
<br />REMARKS: _
<br />-' LABORATORY RESULTS 400
<br />_SEE REVERSESIDEOF PINKCOPY FOR INTERPRETATIONS -
<br />A. COLIFORMS PER 100m1 C. FECAL COLIFORM ❑ RESUBMIT SAMPLE
<br />5TUBEMPN TEST IUI /100ml Teel UnsuitableCnflBemuse:
<br />LMPN aot I. ❑Confluent Growth
<br />1. ❑ -. 0/5 -s2.2
<br />•-E- 2.❑TNTC
<br />2.❑•-- 1/5-2.2/100ml 3.❑FacesDebi.
<br />3.❑- 2/5-5.1 4❑
<br />oE41.Q+ 311 9.2❑ RESUBMIT SAMPLE a,•rat
<br />5. ❑- 4/5 - 16 Sample Rejected Bemuse: (Child, OIro Or Morel
<br />6.0- 5/5 - a16. 1. ❑ Sample Too Old
<br />MF Q / I00MI 2. ❑ Fee Not Provided
<br />J. ❑ Sample Received Too Late In Week
<br />MPN DILN. TESTS 4. [1 Insufficient Information Provided.
<br />/ 100 as - Please Read Instructions On Form.
<br />I.s.eel-_ • _ E _ 5. ❑ Not In Proper Container
<br />B. STD, PLATE COUNT 6. ❑ Leaked Out
<br />7. ❑ Other (Specify)
<br />/ml
<br />ma«�•�E-
<br />REMARKS:
<br />DATE &TIM / I DATE //+C•J./i//��
<br />RECEIVED'','n>) /'-OMPLETED•�
<br />WATER SUPPLIER COPY
<br />
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