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� STATE OF WASHINGTON <br /> � DEPARTMENT OF HEALTH <br /> WATER BACTERIOLOGICAL ANALYSIS <br /> z4MPLE COLLECTION�.READ INSTRUCTIONS ON 6ACK OF GOLDENROD COPY <br /> II instructbn�rte not tolloweE,wmpls will b�n�ected. <br /> �ATECOLLECTED TIMECOLLECTEO COUNTYkAME <br /> MONiH DFY YEAR � I �L � <br /> 7 � � j IO✓ ❑ AM `� PM _,Nc-1U"1/��. <br /> iYPE0FSY5TEM �FPUBLICSYSTEM,COMPLETE�. <br /> ��PUBUC LIP GFOUP , <br /> ❑ MDIVIDUnL ��D.No. Z �1 U � U � � B � <br /> �s.�..�mY�,oa.zn <br /> HANE OF SVSTEM i <br /> : 1 �_�'� �.� � Vi�- i7(' -, —i _ i <br /> SPELIFICLOCAPONWNERESAIAPLECOLLECT�D TELEPMONENO ' <br /> ��/ OAV( LJC � ,, � i����/r".� <br /> � ' ' . , �. �,� , _ i �" � � <br /> EVENiNG( � <br /> S/MP�EWLLECTEJBY.(Namel SYSr'MOWNERMGR.�N�me) �� <br /> � I <br /> ;. ��.�. i��E C � ( t_ �' ��� I'[%'� __ �. <br /> SWRC"cTYPE ❑ GROUYDWATERUN7EPSUFFA�EINFIl�Et6E �. <br /> j�I SUPFACE �", �}'ELLw � SPPoNG � PUACHASEDa L� ��06t6i�lAPON <br /> - wELLFiELO �NtERiiE aOiHER <br /> $E!�0 REPOAT TC �Puni Full Name,id;�esi dM Z�p CoOe� <br /> ,��;� V I_�� �(�i!�:_ <br /> 1� Nt�.1�JP c r:I��C� . i�i,� t ��' `.t �'4�.�6��,:� <br /> iYPE OF SA6�PLE�cnttk ttuy one��n�s cdvmn� � <br /> �] ROUiIFE �] C�MnnaleC�Rev]aal,_.__'o�al_._,I_�f�eel <br /> DflINN19G1YATER � Fdter� <br /> Cli¢CAb¢dlm¢01 � Lj U902dIPCOt01�P�___. _ <br /> f� REPEAi SAAIPLE � <br /> Preno�s coidym qesence La0� ______ <br /> DateCo!i=ne� __ i__ /___ <br /> f='i pdW SOUaCE wATER Sowce� p I �� ic�a!Goi�mrm <br /> �:1' I:EPfCO��SiRUCT10NoiREPAiRS J `. ,J F°�'��'�Cxro�r. <br /> ��J OtMERISDxJyI <br /> REMARKS <br /> (��B USE ONLY�DHINKING WATEH RESULTS <br /> UNSATISFA610RY,Coi�lom�.s piesent '.�SATiSFACTORY <br /> Loidonns a�sent <br /> i�EFEAt -I E Coli presenl : i E Coli absenl <br /> $AI,'PlES -� <br /> �:OJ�pEO—Fecal preseN Fecal absenl __ <br /> OTMEN LpBONq10RY RESUl7S <br /> ipinLCOLiFOaA�_'_'__'l10J�M E.CUII __'_'__'�OOm� . <br /> FLCALCOUFpqA� i16Jml PLATECOUNT <br /> M1NOiHER SAM?lE PE W�flEO � <br /> SAI.!PlEN07TE5TE`JBECAUSE TES7U45U11A9L@NECAISE <br /> Ll $dmple 100 aIC ❑ Co��WBnI gmwlh <br /> ._. Wmngcontainei ❑ TNTC <br /> ._ Inmmpletelo�m ❑ Turb�ticNWre <br /> . . ___ �.� E�ress aeb��s <br /> SE[REVERSE SIDE Of GR[EN COPY FOF E%Pl ANAIiON OF PESULT� <br /> �<FaOi�D�G�*51 �E.ir,iEREGEiVE� AE�EiVE�O� <br /> � jj�l,'/ ) I��. �/ ��I �� I� �` ��- /I'��",,I .� ii, � <br /> � � <br /> OAiEP5Pvi�'EC Lx9CA>1�R! ' <br /> CITY OF EVERETT <br /> �' � � �� � �^�' ENVIRONMENiALLA90RATORY <br /> ", „ , 3200CEDAR STREET <br /> EVERETT WA 98201 <br /> WATER SUPPLIER COPY <br />