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Smle of Wnshinglon - _ <br />Deparlm�nl of So<ivl and eolth Serviaes : - <br />Maahh Serviaei�viaion � � <br />��' SmithTow<r,S�otlie.5lNmhinglon 9B1f14 � �'� • � <br />WATER BACTERIOLOGICAL ANALYSIS - . <br />READ If�STRUCTIONS ON 9ACK OF GQlOENNOD COPY �� � <br />� fF INS7RUCTIONS;ARE NOT PROPERLY FOLIOWED. �. � <br />� � � SAMPIE WIlC9E REJERED. ' � <br />tA8 USE ONIY � CO CITY ie-�m n i:ia� � . <br />�0.: u r ^ .. __ ... <br />' �S� <br />9 COLIECTED��io-xm DATE STARTED �� izn i�e aa - <br />�h DaY Yem 12t ¢m � Y�. <br />17 c7 -��'S��- - R <br />i OF DAY leer I.D. NO. (Pu6Hc Systama) COUNTY NAME .. <br />ECTED O nM l 1311 1321 1331 13O Ii31 .... ' . . <br />�o PM 4 .— <br />E OF WATFR SYSTFM . .. . ,.. . . , . . . _GIRCIE GU.SS. . <br />'�.�:. �iiY 0�-'..�I�R�-i/ �+ 123'd � <br />EM AUOiES p � . ..�.:,. � . . r...:.:.. <br />��/ ' � �Y�� U��''1�.�U ,.� t.. . . :.�...''' ' <br />TION WXERE SAMPL� WAS COLIECTED (fire slotien, school, Sth al.,.etc.) ' <br />�rZi%�r�iJ�`: /'1r�.. .1�/�S"'l�l.(i\�. .. _ <br />TYVEOF t3a� QMuniaipal �� InduvrioL � Privolr . � � <br />� � SYSTEM . � �,Cemmunily °f �iQ Commer�inl or 3 0 Residenro . . . <br />-� -$END REPORT iO:��Prin�.iull Nome; Addrest and Zip Cadep� . , r� - <br />•DAi; o;�) �3��DG�r � <br />� 3 � OO"�C,G D !k2 - ; .,,;s <br />� E J e �� � � �` � , � - ;��+��ioN�„+�,�` �,-�. <br />� <br />� � SOURCE TYPE uvi : ' . . . •' <br />� 105urfacv: 2 _.•:-� -- � .,.. �.. �•• •:..�'a. ...� �'Combinolion. .. <br />� .O Well; 9 Q Spring;; •� Purchaied: '9O e� Other ��.: <br />(�� iYPE OF SAMPIE �3Bb�CHECK ONE ONLY) Ne.�. � Swimming - Swim`m'ing <br />� 1pDrinkingWa�er YOROV� l�Main <QPool SQBeaah � <br />� $anilory .... `�--. : Waler . Shelllish � � � Olher . . ... ..-. <br />6O Su.vey J O Seawa�er 8 � Study 901Specilyl, <br />' IS THIS SAMPIE�A FOLLOW�UP TO A 139I ' - - - � � - . <br />. PRE�IOUS, NON�CONFORMING SAMPIE? 1 Q Yes P� No� <br />IF YES, GIVE PREVIOUS LAB. NO, <br />i mvi SYSTEM TREATMENT (Check only lor Drinking Waier Somple5) <br />�. iQNone: 2�Chlarinolion; 3QFilva�ion; 40Fluoridation; � <br />�� � � 900�her�5pecify) . . . . ". <br />i <br />REMARNS: - � _ � - . <br />� ._.., . i ' .,.. . :i� .. .. .. . <br />� , � . LA60RATORY FESUlTS \ � <br />� SEE REVFRSE SIDE OF PINK COPY FOR INTERPRETATIONS . � <br />. A. COIIFORMS PER IOOmI C. FECAI COLIFORM � ❑ RESUBMI� SAMFIE <br />, 5 TUBE MPN TEST �um ' / �OOmI T°s� Unwitable Be<awe: ' <br />MPN <br />�, I.O��0,�5=Q.Y no�1.�ConllocnrGrowth <br />. ' mv.sa_._E_ .. . <br />2.�--�1/5=4.2 � 2.�TNTC <br />� 3. O�+Y/5 = 5.1 MF /�OOmI � Q E:cros Dehriti <br />� -...�.: �ei-en_•_E_ ' 4.0 � . <br />4.�—�J/5=9.� . <br />I 5. O�� 4ji = 16 � RESUBMIt SAMPLE ��i-�a� . <br />' .SomRle Rejecled Because: �Check One Or More1 <br />6. �� 5/5 =>16 �, ��Somple Too Old � � <br />( MF_ /1 / 100m1 2, 0 Fee Nol Pm.ided ' , <br />�sbam�l ✓1 E� 9. � Sample Recei.ed Too Laie In Week , <br />iMPN DILN. TE5T5 . 4. � Imul' :iem Inlormmlon Pro.ided. <br />/100m1 p�p��e Read Intlr�ttlant On Form. <br />� las.ae�_�_E� 5. � Not In Pmpe� CoNainer <br />I <br />i B. STD. PLATE COUNT 6. � Leaked O�t <br />� � � Z�Othe.ISpecilyl � . <br />ISJ�3B1_� E. <br />� <br />�, DATE d iIME <br />' RECEIVED 7., <br />WATER SUPPLIER COPY <br />. �' <br />� � � <br />' � � � / <br />/ <br />\ ! <br />�_— �' <br />