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� osNs ia.m,ni.en <br /> � STATE' WASHINGTON <br /> � ' � � UEPARTMENT OF SC �AL�ND HEALTN SERVICES � � � <br /> WATER BACTERIVLOGICAL ANALY�IS <br /> sn avi�co��i�c�ior:� n�no cr,�i�uci����:c ar� onck nr r,oi ur:r�un curv <br /> If instructions�re not lollowed, ,ample will be rejected. <br /> DATF.COLLECTED TIMECOLLECTED COUNTYNAM[ <br /> MONTH DAY YEFR r7� ' r � <br /> � �_�., � - - ?O AM � ❑ PM � , <br /> iVPE Of SYSTEM IF PUBLIC SYSTEM,COMPLETE: <br /> Q PUBUC CiFREClti55 <br /> � ❑ INDIVIDUAL I.D. No. ��;Z 3 q <br /> �� onp i�e:m.��ni - . <br /> . NAME OF SYSTEM , r- <br /> r, �' <br /> �i , . . . . ,. . . ,( � . � _ � <br /> ' �PiCIf�C LOCAlION W'HEPE SAMPLE WLL�CTEO S�SiEh7INJNEFl/NGF k4ME ANDTELEfHONC H0. � <br /> � o� ���cnen up a senodJ✓�s�aeoo.mumrn� � <br /> I <br /> .. . 1: . .\ � . <br /> SAMPLE JOLLECTED BY:)Namo� <br /> ��-�i I 'li _ ., _ . <br /> SOURCEiYPE - � � <br /> ❑ SURFACE ❑ WELL ❑ SPRING � �PURCHASED ❑ "OMBINATION <br /> or OTHER <br /> SEND PEPORT TO:IPrlm eull Nama,ACdres=ana Zlp CoOo� � <br /> �� "'�.:� \��'fn <br /> _,� <br /> _—" � / ' <br /> - � •yegryINGTOR �° 'i <br /> � TYPE OF SAMPLE <br /> � (G�eGk OnIY OM in I�i]cDlum�) <br /> , ❑ Chlorinated�Residual:_Total_Free) ' <br /> ' 1. ❑ DRINKING WATER � <br /> �. c�eck trealment� � Filtered <br /> � ❑ Untfea�CO or Olhof <br /> ', P. ❑ RAW SOURCE WATER ' , <br /> � 3. 0 NEW CONSTRUC'ION or REPAIRS � <br /> ' 4.�❑ OTNER�Specily�_ �. <br /> T I <br /> COMPLETE IP THIS SAMPLC-IS A CHECK SAMPLE <br /> i PIIEVIOUS LAB R0. � <br /> , PREVIOUS SAMPLE COIIECTION DATE � <br /> REMAFKS: <br /> � LABORATORY RESULTS 1Foa�ne use oN�v� � <br /> � MPN�COLIFORM STO PLATE COUNT SAMPBEC USECSTED , <br /> � �5 wm.ro+m..� �ml <br /> �, MPN[)ILUTION � TESTUNSUITABLE � SampleTooOltl �, <br /> ' �00 mi��, Q-�oniWent Gmwth ❑ Mot In Proper Conlalner <br /> � IdF COLIFORM � <br /> Q, Q TNTC � IneullicienYlnlormation <br /> �00 mi Pmvlde0-Plex�e Read <br /> � Instmclions on Form <br /> ' FEC�LCOLIFORM 3.� ExcessDebds � � <br /> �. ❑ IdPN C MF 4 � � <br /> �_�00 rtJ <br /> . � FOR DRINKING WATER SAMPLES ONLV;THESE RESULTS ARE: ' <br /> � ❑ 5A71SFAC70RY � . ❑ UNSATISfAC70RY _ <br /> SE'c f1EVEFl5[SIQE OF Gfi[�II LOPl'F'OFl EY.aLANATIOq OF RES�LT i <br /> ' LA�NO. DATE.TIMERECEIVED- �l/�S(D REGEIV:OBY � <br /> / � <br /> �' � � ��� � �-�C-��� <br /> �ATE REPORTEO �1 LABORATOflY: - _ � <br /> ) {' <br /> � `1_7 <br /> � REMA NS ' � �. <br /> WATE9 SUPPLIER COPY va� <br />