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DSHS 13-173 (R181) <br />\) STATE OF WASHINGTON <br />/ DEPARTMENT OF SOCIAL, 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 />DATE COLLECTED TIME COLLECTED COUNTY NAME <br />1l�(TH deY Y R <br />N/� ❑ AM ❑ PM <br />TYPE OF SYSTEM IF PUBLIC SYSTEM, COMPLETE: <br />s... <br />CIRCLE CLASS <br />�'FGBIN �,p; Ne. ,CI 2 3 S <br />��. h.k;' <br />INDIVIDUAL <br />ummk wlr I mroen<m <br />NAME OF SYSTEM <br />�jREC-�2fx <br />WHERE SAMPLE COLLECIED SYSTEM OWNER/MGR, NAME AND TELEPHONE NO <br />i, <br />SPECIFIC LOCA110N <br />Pa. kuome Ian a SOW. I'rG Btanw_. I <br />., <br />SAMPLE COLLECTED B jtNam <br />❑ SURFACE ❑ WELL ElSPRING InPURCHASED ❑ or OTHERTION <br />SEND REPORT TO: W,lnl Full Name, A Tess and Zip Code) <br />EEWASHINGTON <br />TYPE OF SAMPLE 1 <br />ICM[k only. M mlf rnlumn) <br />1. ❑ DRINKINGWATER ❑ Chlorinated (Residual: _Total_ Free) <br />check treatment —1 ❑ Filtered <br />,I - ❑ Untreated or Oth4r <br />2. ❑ RAW SOURCE WATER <br />3. ❑- t1EW CONSTRUCTION or REPAIRS <br />4. ❑ /OTHER (SPeclfy) <br />COMPLETE IF THIS SAMPLE IS A CHECK SAMPLE <br />PREVIOUS LAB N0. - - <br />PREVIOUS SAMPLE COLLECTION DATE <br />.. REMARKS: — <br />LABORATORY RESULTS tFOR LAB USE ONLY) <br />MPN- COLIFORMI <br />STD PLATE COUNT <br />SAMPLE NOT TESTED <br />�5 weak oa.n,.a <br />�ml <br />BECAUSE: <br />MPN DILUTION <br />TEST UNSUITABLE <br />❑Sample Too Old <br />�00 ml <br />�. ❑ Confluent Growth <br />❑ Not In Proper Container <br />2. ❑ TNTC1 <br />.❑ Insufficient Information <br />�00 ml <br />�'�• n <br />Provided —Please Read <br />Ru <br />FECAL COLIFORM <br />❑ MPN MF 4 ❑ ❑ <br />0/CO ml <br />-- ER SAMPLES ONLY. THESE RESULTS ARE <br />FOR Dj+INKING WAT:. <br />9MrSATISFACTORY ❑ UNSATISFACTORY <br />rSEE REVERSE SIDE OF GREEN COPY FOR EXPLANATION OF RESULTS <br />LAB NO. DATE. TIME RECEIVED— CENED BY <br />050044 1 . _ - n. A <br />WATER SUPPLIER COPY es <br />