1007 SE EVERETT MALL WAY 2016-01-01 MF Import

.. osHs iyin�aiai� osNs u��n iA�a» ((..'y,\J STATE�OF WASMINCTON STIITE OF WASHINGTON �c:r.� 'DEPANTMENT OF SOCIAL AHD MEALTHSERYICES!� �� DEPAqTMENT OF SOCIRL ANU HEA�TH SENVICES� WATER BAGTERIOLOGICAL ANALYSIS �NATER BACTERIOLOGICAL ANALYSIS # SAMPLE COLLECTION' HEAD INSTRUCiIONS UN BACN Of GOLDENROD COPY SAMPIE COLLECTION� REAO INSTPUCTIONS ON BACK OF GOIORIRO� COGY If instrucUons are not lollowed,sample will be re�acted. II Instructions are not followed,sampte wi�l be relected. �ATE WLLEG7ED 11M COLLEGTED COUNTY NAME DA7ECOLLECTED TIM OLLECTED COUNTY NAME MONTM UAV YEAH � :� UU I MONTN DAY YEAR � . QU L p�f S 3c� S�� AM ❑ PM Sn�h. S �J �S (� AM ❑ PM ��u "'. 1�: TYPE OF,SYSTEM �F PI/ByIC.8Y5TEM,COMPLE7E 7VPE OF SYSTEM IF PUBLIC SYSTEM,COMPLETE: �� �YFlJBLIC��' [ ��ACLf CU55 �PUBUC CIRCIE C1A55 �', [I IN01 IDUAL �•D. No. � p 3 q ❑ INDIVIDUAL I.D. No. � Z � 4 fff ne,.e�mn�rn�rce� ue...�omr�,.uamc.� �'. NAMEOFSYSTEM NAMEOFSYSTEM �,}� � �',�' p� �JQK4 '1 O �UQrQQ � SPECIFIC LOCAi10 WNEflE SAMPLE COLLECTEU SYSiEM O�4NEF/MGP.N4MElJJ�fflFR1QNE N0. SPELIFlC LUCATION WNEPE SAMPLE COLLECTEO SVSiEM ONNfA/MGII.INMEANO iELERqNE N0. 4 �K.eitmn uo a �woL 1im:uuoa iwmuN/`� 1 T ✓ �H�ncnen uo a roa.i��e u.00n.iwniuni � �/ / � �MU�n .,ERfI`�'17�6r�. .�� y 01 l.X+F/�/ N1a�.l �w �t✓�>�o.nC CA�}� Of �UP/Cl'/'Y�' � �1 ( r� 1 f p �OO/ �. tY � f1'I:� II l,V• ( ) .Z'�S'� C/� �OO E. �VT. MQII l'VP ( ) �� 7'� O/� � ? SAMP��ECTED BY:INamel �. SAMPLE COLLECTED BY:IName� ( //_^ �. �P�IW�L�M j Vn �P�m4r� j SOURCE7YPE �� SOURCE7YPE � COMBINATION ❑ SURFACE ❑ WELL ❑ SPRINC ❑ PURCHASED ��BINATION � ❑ SURFACE ❑�WELL O SPRING ❑ PURCHASED �orOTHER orOTHEF I SE!ND,�REPORTl TO:�Pnnl Ful�Name,ntldr�e3a antl Zip CoOe) SEND REPORT TO:�Pnm FW�Name,Aeemss mE Zip CoOe) � V/�� nf F�c�zrN 1��6�c `i_/ JKA} � o�' E .iP2f� }'f �%�n�i �� f• / .�i. � � 1 3 Zc�o C�cta. SI �io .� C�c�o. SI. 4� C-,�o.ve ff J�'Yi.O/ F_ ..� t�rtv �t' 91'%-0/ 1. _ _WASMINGTON WASMINGTON ( TYPE OF SAMPLf TYPE OF SAMP�E h ieroa mM me m im.cd�mm iei+c�mir uv m mn caw�p _ �. � � �� �. ❑ URINKINGWATER � Chlorinale4�Residual:_Tolal_Free) 1. � ORINKINGWATER ❑ ChlorinateA�Residuai:__Total_Free) � check Ireatment—� ❑ Filteretl - check�reafinenl—� ❑ Filtered ( ❑ Untreatetl or Other . ❑ Unireatetl or Oiher Z. ❑ RAW SOURCE WATER � Z. ❑ RAW SOURCE WATER ' $.L�NEVJ CONSTRUCTION or REPAIR$ 3. �NEW CONSTRUCTION or REPPIRS �� 4. O OTHERIS�ecily) 4. O O7HER(Soecily) _ �• COMPLETE IF THIS SAMPLE IS A CHECK SAMPLE COMPLETE IF (HIS SAMPLE IS A CHECK SAMPLE �, Pfl[VIOUS lAB N0. PflP90U51A0 N0. � PREVIOUS SAMPLE COLLECTION DATE PREVIOUS SAMPLE COILECTION DATE � AEMARNS: REMARKSC: / — �� ✓' � � JN�«�Y� � / � �` LABORATORY RESULTS(�oa�Ae use odtp LA80RATORY RESULTS 1Fon i�e use oN�v� MPN�COLIFOFM STD PLATE COUNT SAMPLE NOT TESTED MPN��OLIFORM STD PLAiE COUNT SAMPLE NOT TESTED � � BECAt15E: —/5 uM �1.e �m1 �ECAUSE: 5we�.00a��.� ml MPN DILUTION TESi UNSUITABLE � Sample Too Old MPN DILUTION TEST UNSUITABLE ❑ Sample Too O�tl �00 ml �, Q Conlluent Gmwlli � ❑ Not In Pmper Contalner ��m� 1• ❑ Conlluenl Growlh ❑ Not In Praper Conlainor MF CQIJFORM MF�OR0.1 Z. ❑ TNTC � Insullicienl inlormation 2. � TNTC � Insulliclont Inlormation _��00 ml Provided—Please ReaO �00 mi Pmvitle0—Flease Reatl 3. � E:cess Debris �nslmctians on Furm , 3. ❑ E�cess Debris Instruclions on Form FECAL COLIFORM FECAL COLIFORM ❑ MPN ❑ MF 4 � ❑ MPN ❑ MF 4 � �00 ml � �00 mi � FOq�O,,(�RINNING WATEH SAMPLES ONLY,THESE RESULTS ARE: FOR DFIINKING WATEfl SAMPLES ONLV,THESE RESl1LTS ARE: lLJ SATISFACTORY ❑ UNSATISFACTORY �SATISFACTORY ❑ UNSATISFACTORY L� EF RFVFRSF SIUE OF GREEN f,OP�FOR CNPLANnTIGN OF RESUITS �FE �7EVE�iSF S�DE OF GREEN COP�FON E%PIFNATIO"I OF RFSUI.TS LAB N0. /_'7 C./ O�TE,TIME RELEIVED— RECEIVED BY �B��o� � � 65 OQE,TIME REGEIVEO— RECEIVED 6Y (UO`0(p �_ . � � , �� -, � �, _ r. � ' ': L J :,. ,� v u ' �S �� -�� t l. r v ., u 5 "�O�S �TE�REPo,�D / � � RRTORY: ��E REPQii�E / BORATOFY: _ pEMARKS REMARNS �qpTrn C!��PI IF� f nov a. WATER SIIPFUER COPV T� `i