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DSHS 131 W3 (RI 81) <br />STATE OF WASHINGTON \) <br />�} DEPARTMENT OF SOCIAL AND HEALTH SERVICES / <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 />` MONTIf Y YEAR CJ'V <br />k W AM -PM <br />�{�7l <br />TYPE OF SYSTEM IF UBLIC SYSTEM, OMPLETE: <br />C# PusI.D. No. <br />CIRCLE CLASS <br />1; z 3 4 <br />a `_ <br />❑INDIVIDUAL <br />! <br />laen'es �h t eudewel <br />NAME OF SYSTEM `�rI�Y�ACt' E,`r'j� � � <br />��zIT'll✓�l�p-�`-\JI.i' <br />�'. <br />it <br />73 „ <br />SPECIFIC LOCATION WHERE SAMPLE COLLECTED SYS M CMv ER MGRI NAME AN TElEPNONE 40. - <br />4e. xJ Oo a xMCIjpm flatbn, lwmainl <br />�an <br />/�AA\ <br />. ... <br />SAMPLE COLLECTED BY: (yi, me) <br />SOURCE TYPE r '''rrryyyL—U OMBINATION <br />❑ SURFACE ElW�LL El SPRING � PURCHASED or OTHER <br />SEND REPORT TO: (Pnm Fuif Name,A15)res and Zip Code), <br />� 5C . <br />/IA)dA F�l1f WABHIHGTON <br />�fv <br />A <br />TYPE OF SAMPLE T <br />ICnecx onh ww in tl,b edumnl <br />1. ❑DRINKING WATER ❑ Chlorinated (ReSldual:,Total_Free) <br />Check treatment ❑ Filtered <br />:1 ❑ Untreated or Other <br />2. ❑W SOURCE WATER <br />3EW CONSTRUCTION or REPAIRS <br />4 THER (Specify) <br />COMPLETE IF THIS SAMPLE IS A CHECK SAMPLE <br />PREVIOUS LAB Nu — <br />PREVIOUS SAMPLE COLLECTION DATE , <br />RFMAGKC< <br />LABORATORY RESULTS (FOR LAB USE ONLY) <br />x <br />I Ir f '�:,• <br />MPN - COLIFORM STD PLATE COUNT SAMPLE NOT TESTED <br />h ' <br />r <br />/ml <br />_/S�oeea ooam.e <br />❑ Sample Too Old <br />MPN DILUTION TEST UNSUITABLE <br />i <br />/100 ml T. ❑ Confluent Growth ❑ Not in Proper Container <br />MF LI RM 2 El TNTC El Insufficient Information <br />�00 Is,Provlded—Please Read <br />instructions on Fam <br />3. ❑Excess Debris <br />FECAL COLIFORM <br />❑ MPH ❑ MF 4 ❑ ❑ _ <br />/oo ml <br />r�.'tn.•., <br />I <br />FOR DRINKING WATER SAMPLES ONLY. THESE RESULTS ARE: <br />SATISFACTORY ❑ UNSATISFACTORY <br />SfEE REVERSE SIDE OF GREEN COPY FOR EXPLANATION OF RESULTS <br />ham, l <br />— <br />LIB N0. DATE, TIME RECEIV'_D— RICEIVEC BY <br />WATER SUPPLIER COPY <br />1_ <br />AS.nLy t `' �+ n a� <br />Fiat , : w <br />