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. DSHS Uq]31AL81) <br /> S7"ATE OF WASHINCTON � <br /> DEPARTMENT OF SOCIAL AND MEAUH SERVICES � <br /> WATER BACTE:RIOLOGICAL ANALYSIS <br /> sn�.�ri t_ cnu_Ecnnrr rEno u�srnucn�;�:s o�: unc; or r,nnccnou r,a�v <br /> If instructions are not lollok•�d, sample will be re�ected. <br /> DATE COLLECTED TIME COLLECTEU COiINTV NAh1E <br /> IdCNTH DA'i VEAR . <br /> - . . � ,"l •� � <br /> � � � .c_. ❑arn � p aM <br /> TYPE OF SYSiEM IF PUBLIC SVSTEM,COMPLETE: � <br /> �� ❑ PUsuc I.D. No, c ciennss <br /> ❑ INDIVIOuaL "1�2 3 q <br /> i.�. r i�e.�aro�e� � <br /> NAMEOFSYSTEM . . <br /> - . . . . + . . � - .. , <br /> SPECIfIC IOCAiION l4HEPE SAMPIE COLLECiEO SVSiEMUVAEfl/MG7.NAMEFN�iELER10YEN0. <br /> � I�e xnro:n ijo e�scnocl wo eunoo.�omuinl <br /> � I_�.I �� , ;�l � � � <br /> SAMPLE COLLECTED BY:�Name� <br /> . ... .� � � .,, i � _. . . /;� <br /> SOURCETVPE <br /> C Sl1RFACE CI WELL ❑ SPRING ❑ PIIRCHASED ❑ ��°�THIE�TION <br /> SEND REPORT Tp;�p�i��PoII Name;AtlJrms antl ZiD��de� <br /> � 1, <br /> _ .ii. , � . � ..�'� . <br /> �, WASHINGiON ' ' ���� <br /> TYPE OF SAMPLE - <br /> �' ICnnc�oniy ona in ino mWmn� <br /> � <br /> � 1. ❑ ORINKINGWATER � Chbrinaletl�Resitlual:_Tolal__Frea) ' <br /> check Irealment�� Filteretl <br /> , r� Unlreated or Ol�er <br /> 2• ❑ RAW SUURCE VJATER ' <br /> ' 3.,0 NEW CONSTRUCTION or REPAIRS <br /> � 4. ❑ OTHER�Specily) ' <br /> COMPLETE IF TMIS SAMPLE IS A CHECK SAMPLE <br /> PAFVIO�!5 LAd NO— � ��� `I <br /> � PREVi0US5AMPLEWLLECTION�ATE ���'�� '��" <br /> REMARKS <br /> LABORATORY RESULTS�FOA�ne use oN�rl , <br /> MPN-COUFORM STD PLATECOUNT I SAMPLE NOTTESTEO . <br /> _�5 wo<s voe�e,• BECAUSE: <br /> �ml <br /> MPN DIWTION TEST UNSUITABLE � Sample Too Old i <br /> �. �00 m� �, Q Conlluent Growlh ❑ Not in Proper Contalner <br /> � MF ppLIFORh1 <br /> 2. ❑ TNTC � Insu111cienYlnlormalion <br /> 1��DO ml Provided—Please Reatl <br /> FECAL COLIFORM <br /> 3. � Eacess Debris Instmctlons an Form ' <br /> ❑ MPN ❑ MF 4 � ❑ <br /> �JOmI — <br /> FOR ORINKINC WATER SAMPLES ONLY,THESE�r�ESUL7S ARE ' <br /> ,�I SATISFACTORY ❑ UNSATISFACTORY � <br /> SEE fi[YEftSE SIDf OF GRELN COPY FOR EkPUY�TION OF RFSULTS �� <br /> - U8 NO. �. OATE,TIME RECEIVEO— �f.� lCEIVED BY . <br /> . pJ n r . /� '. �J <br /> �� 3 .�S /'c� (O <br /> OAS��iEPh1RTE LABORATORY: � <br /> �%/��7 bh <br /> PEMARKS <br /> WATER SUPPLIEFI COPY ,as <br /> t <br />