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DSHS n 170IR181) <br />STATE OF WASHINGTON <br />DEPARTMENT OF SOCIAL AND HEALTH SERVICES�T`\+,1 <br />WATER BACTERIOLOGICAL ANALYSIS <br />SAMPLE COLLECTION: READ INSTRUCTIONS ON BACK OF GOLDENROD COPY <br />If instructions are not followed, sample will be rejected. <br />DATE COLLECTED I TIME COLLECT I COUNTY NAME, <br />MONTH DAY YEAR /,��? <br />U AM ❑ PM Ij V o <br />TYPE OF SYSTEM I IFPUBLIC SYSTEM, CUNI I E: <br />❑ PUBLIC ciacLL CLASS <br />❑ INDIVIDUAL I.D. No. <br />me.ee nnq r e»oencel <br />NAME OF SYSTEM <br />SPECIFIC LOCATION WHERE SAMPLE COLLECT D SYSTEM OWNLA/MGR. NAME AND TELEPHONE NO. <br />.e. 4ilc14n Ro a 5<nWl, Lie alelion.IWor <br />2- � 1 <br />C� <br />b) o <br />SAMPLE COLLECTS BY: (Name) <br />AC-� <br />SOURCE TYPE <br />❑ SURFACE ❑ WELL ❑ SPRING ❑ PURCHASED ❑ COMBINATION <br />or OTHER <br />SEND REPORT TO: W : Fr II Nam dress and Zip Cotle) <br />V (AJE, <br />_ WASHINGTON <br />TYPE OF SAMPLE <br />Ienecx only one,n iota tolamry , <br />1. ❑ DRINKINGWATER ❑ Chlorinated(Residual:_Tolal_ Free) <br />Check treatment --� ❑ Filtered <br />❑ Untreated or Other <br />2. ❑ RAW SOURCE WATER <br />3. El IIEW CONSTRUCTION or REPAIRS <br />4. ❑ OTHER (Specify) <br />COMPLETE IF THIS SAMPLE IS A CHECK SAMPLE <br />PREVIOUS LAB NO. ';? a <br />PREVIOUS SAMPLE COLLECTION DATE <br />REMARKS <br />LABORATORY RESULTS (FOR LAB USE ONLY) <br />MPN-COLIFORM <br />STD PLATE COUNT <br />SAMPLE NOT TESTED <br />�5 roxa aovH.e <br />_ <br />�- AR <br />BECAUSE: <br />MPN DILUTION <br />EST UNSUITABLE <br />❑ Sample Too Old <br />/100 ml <br />1. <br />_. dnt Growth <br />❑ Not In Proper Container <br />MF COLIFORM <br />2.A TNTC <br />❑ Insuflied— lease <br />/00 ml <br />Provided— dead <br />lead <br />3. <br />6 Excess Debris <br />Instructions on Farm <br />FECALCOLIFORM <br />❑ MPN ❑ ?AF <br />4. ❑ <br />❑ <br />/100 ml <br />FOR DRINKING WATER SAMPLES ONLY, THESE RESULTS ARE: <br />❑ SATISFACTORY <br />❑ UNSATISFACTORY <br />SEE REVERSE SIDE OF GREEN COPY FOR EXPLANATION OF RESULTS <br />LABy NO. A <br />:)'-,I <br />DATE, TIME RECEIVED—yry <br />, RECEIVED BY <br />c, <br />t— / <br />DA EPORT'D <br />BORATORY: <br />_ <br />REMARKS OF <br />WATER SUPPLIER COPY <br />r. <br />