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.. os�s».r,aiR�en -. � <br /> � <br /> � ^' STATE OF WASNINGTON , <br /> ... OEPARTMENT OF SOCIAL AND NEALTM SEflVICES�L. ' <br /> WATER BACTERIOLOGICAL ANALY�IS � <br /> SA!dPLE COLLECT10Y: fl6101N51311CT10N5 OY BACK OF GOLDENH00 CfIPY <br /> II inslructions are not followed, sample will 6e rejected . <br /> DATECOLLEqED TIMECOLI.cCTED COUNTY NAME . ' � � <br /> MOaiH / OAY YERR �/! �//�� <br /> /� S�/d_ <br /> 4 SCa AM . ❑ PM11 <br /> TYPE OF SYSTEM IF PUBLI SYSTEM,CONPL[TE: <br /> . _ . . . . . . .. , �auauc I.D. No. naacanss _ . . -.._ <br /> ❑ iNomoun� J 2 3 a <br /> �,.�,��,�,.,,a.M.� <br /> . NAMEOFSYSTEM��� _����� <br /> - Q ^ � <br /> SPECIFIC IOCAT100 WM FE SA1APlE COLLECTED SYSiEM QNNEP/lAGB.tUJdEFt:D7FlER!0'JENO. <br /> �- o..nuv�iae n smmi.un eueo�.rwowo� y <br /> - . : ,,... '�..,:., 'O,J �P�P7Jc <br /> `'�'7 .-0 �Ok' ''S`j��i l <br /> SAMPLE COLLECTED BY:�r+arael <br /> '�',�..::�2�\-�--�—�- <br /> - � SOURCETYPE � y � <br /> � ❑ SURFACE ❑ WELL ❑ SPflING � PURCHASEO � COM6INATION . <br /> . . . . � orOTHER _, . . . . . . <br /> � S.ND FEPORT TO:IPr�m Dwi Nam�p(tlEmss an0 Zip Cotle� - , <br /> �� K�Efl�SWf'c� �[ �� <br /> ti . ... ..A'_.i:H M.r.�.�n\�`.�l ..�..n.1 . . /'`��/�/�/� l >pc.ii �'N�Y.t�NH'!..i.�i. <br /> .�� ( C�/h'/C�". / '`.ia..�.0.'./�/`J . . <br /> �.. . - . . � . � i /�l��_WASHINGSON � � . . . . <br /> TYPE OF S.CMPLE _ <br /> " �CMc�mry m�in mu cmvmq <br /> ' . ,. . . . . '`'_.� � - . . . . . �.. . . <br /> ' 1. ❑ DRINKINGWATEF � � C�IorinatctllResitlual:_Total_Free) � <br /> . .� ( checktreatment--� � Fi!tered �� � _ <br /> .. •. � � i _ . .❑ Untreated.or ONer � � � . . ,- . - <br /> . ,j 2. ❑ RAW SOURCE WATER ' �. . <br /> � i 3�NFW CONSTRUCTION or REPAIRS � � ' , <br /> 4 OTHER(SOecify) - <br /> ' . COMPLETE IF THIS SAMPLE IS A CHECK SAMPLE , � . ' - <br /> ... � . . . . . . . . , �1 _ . PflEV10U5lAB N0. .. . ' . . . . . . <br /> y <br /> � PREVIOUS SAMPLE COLLECTION DP.TE � . <br /> REMARKS: - <br /> - LABORATORY RC-SULTS IFup�ne use on�v� � <br /> h1PN•WUFORM STD PLATE COUNT ' SAMPLE NOT TESTFD . . . . <br /> � BECAUSE: . � <br /> �5�w..oo.�u.. �ml . <br /> MPN DIIUTION TEST UNSUITABLE ❑ Sample Too Oltl � � <br /> �00 ml �, � Conlluent Growt� ❑ Nol in Proper Container <br /> MF�RM <br /> 2, ❑ TNTC � Insullicient Inlormatlon <br /> �00 mi Provitletl—Please ReaG <br /> Inslructions on Farm <br /> ' FE7AL COLIFORM 3. � Ezcess�ebris � <br /> . . . . ._ . . . ... . . . .. _.-...! CJ MPN ❑ MP A. ❑ . ❑ . .. . .' . <br /> � �4Cml <br /> , �F ORINKINai WATERSAMPLESONLY,THESEflESULTSARE: � <br /> SATISFACTORY � ❑ UNSATISFACTORY <br /> ., SEE REVERSE SI�E OF GREEN COPY FOR E%PLANA710N OF RESULTS <br /> �q6y0^� � �� OATE.TIMEfiECErvE�— �/�. RECEIVE� <br /> b ' <br /> ., � <br /> -`/-.3-:i,6 fI� <br /> ���• DAT REPORTE 1A90FiAi0Rl'�' <br /> 1�� ! ���i :�l � <br /> REMAANS � <br /> � <br /> WATER 3UPPLIER COPY ?: <br />