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� GSN$q-V J IA1.N'1 <br /> STATE OF WpSHI.JGTON , <br /> , DEPqRTMENT OF SOCIAL AND HEALTH SEflVICES I <br /> WATER BACTERIOLOGICAL ANALYSIS I <br /> SAMPLE COLLEG110N. REAO I'JSIRUC110N5 ON BACK OF GOLDfitlRDD CDPY <br /> If instructions are not loilowed, sample will be rejected. , <br /> DATE COLLECTED 71ME:COLLECTED I COUNTY NAME . <br /> , MONTH OAY YEFR " <br /> � � �� 'i�„��� ._ I <br /> '�� I Z r �•- ❑ AM � (� PM _ . .�� I <br /> I TYPE OF SVSTEM IF PUBLIC SYSTEM,COMPLETE: i <br /> ' ❑ PUBUC GL^RE[tass <br /> � ❑ worvioua� �•D. No. � I <br /> �f�2 3 4 <br /> . omv�re�m���m <br /> �, NAMEOFSYS7EM ' <br /> �" <br /> i � K-���_— � <br /> SPEQFif,LOCAiION WIIEPE SAM7LE COILECTED SYSiCMONNER/MGfl NAMEAN�7ELER10NEN0 � <br /> ' oe .nr.ne�mo r,.anxi.r.�.zuuon�o�,�u��� , <br /> r' z !�1.UOLF _ i <br /> � � <br /> C_ 7, N��eTly� N �, <br /> I SAMPLE COLLECTED BY:�Nemc� i <br /> � ��.� �LULQ-l\. �ti'f,vt I <br /> ' SOURCSTYPE \ � <br /> ❑ SURFACE ❑ WELL ❑ SPflING F�'P(qCHASE � COM8INATION I <br /> i or OTHER I <br /> !, $END FEPORT TO:�Pnm fun Name,�44 ess ana Zip Co0¢� .. — <br /> � r-�� .��nJ�.YI�,. � <br /> � �? .-���, C-Ci)r1+Z <br /> I <br /> : <br /> i �.�•�---^'�. 1 W�SHINGTON ^"i <br /> ��_ <br /> iYPE Of SqMPLE �. � I <br /> . �Gec am�wm�nmucm�mn� � <br /> ' � � �1 l� ��� I �� � <br /> j 1. Q DRINKiNGWATEF � C'�Iorinate0(ReSi�i�I:�Ro�� ree)i <br /> I c�eck Ireaiment� � Filleretl�i i �i <br /> ❑ Unirealetl or O�Fier� � <br /> . P. � RAy.'50URCE WATER ' '� .^U' I <br /> 3. I!��EW CONSTRUCTION or REPAIRS I <br /> � 4. � OTHER(SPecilyl— ._.................. ...._.,..._.......,.._..........�.. � <br /> �—�+—c•--T•�•.�,-- � <br /> COMPLETE IF 7NI5 SAMPLE IS A CHECK SAMbL'E �'' `-'"' ' ' � <br /> �� ( � l�. . �qr . � I <br /> PflEVI0U5fABN0 � �- '� ����� �� i <br /> PREVIOUS SAMPLE COLLEClION DATE— ��—S I <br /> '� REMARKS. � . .. � <br /> �� LABORA"lORY RESULTS IFoq�na use oN�v� � <br /> . MPN�COLIFORM STO PLATE COUNT SAMPLE NOT TESTED �i <br /> �5�m�.i�-,se�.,. BECAUSE: I <br /> �ml <br /> ' MPN DILUTfON TEST UNSUITABI.E ❑ Sample Too OIU ; <br /> �On mi � �] ConlWenl Growt� ' <br /> ❑ NoI In Proper Conlainer i <br /> MF COL1 RM <br /> - �� 2. � TNTC � '�suilicienl Inlormation ' <br /> �LO mi PmviOetl—Please Reatl I <br /> FECAL COLIFOPM <br /> 3. � Excess Debris Ins�mctions on Form � <br /> � ❑ MPN ❑ MF 4. ❑ ❑ . <br /> �00 ml <br /> FOR DJiINKING WATER SAMPLES ONLV,THESE RESULTS ARE: ,� <br /> ���'�SATISFAC70flY <br /> � ❑ UNSATISFACTORY <br /> � EE PEVERSE il[JE OF GqEEN COPY FOfl EXPLANATION OF RESULiS ;' <br /> LFB N0. DA7E.TIME RECEIVED— RECENED 6Y � <br /> � � <br /> ?lr� if��Z. ��- >�� � /, /_ <br /> ORTE RE ORT IRBORATORY: <br /> 1'^ � <br /> flEM � � '� <br /> � �. <br /> \NATGR SUPPLIER COPY <br />