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I"-tI 11 73dt1 <br />STATE OF WASHINGTON <br />DERIATMENT OF SOCIAL ANO HEALTH SERVICES <br />WATER BAC7Is <br />10�(�GIFAL ANALYSIS <br />SAMPLE COLLECTION' R A.1T UCTI�ONS ON RACK OF GOLDENROD COPY <br />If instructions are not followed, sample will be rejected. <br />UATECOLLECT ED <br />TIME COLLECTED <br />COUNTY NAME <br />MONTH DAY <br />YLAR <br />YiJ <br />I D <br />J I <br />9 AM ❑ PM <br />S1,40/. Irvu <br />S/% <br />TYPE OF SYSTEM <br />IF PUBLIC SYSTEM, <br />COMPLETE'. <br />[k PUBLIC <br />eant [k455 <br />❑ INDIVIDUAL <br />I.D. <br />No. <br />1 2 3 4 <br />Isenrs only t resmenrel <br />NAME OF SYSTEM <br />SPECIFIC LOCATION WHERE SAMPLE COLLECTED SYSTEM OWNER/NIGH NAME & TELEPHONE NO <br />(le, kitchen tap @ school. life station, tountem) <br />N LN,> r nl/1lN <br />SAMPLE COLLECTED BY: (Name) <br />11 L v y r <br />SOURCE TYPE <br />❑ SURFACE ❑ WE-L ❑ SPRING PURCHASED ❑ COMBINATION <br />or OTHER <br />SEND REPORT TO IPnol Full Name. Address and Zip Code) <br />a <br />j I r� � i7 l' ) l WASHINGTON ti'�'C EJ l <br />TYPE OF SAMPLE <br />(CheV, only one in this column) <br />1. ❑ DRINKING WATER ❑ Chlorinated (Residual: _Total _Free) <br />checktreatnteel ❑ Filtered <br />❑ Untreated or Other <br />2. ❑�RAW SOURCE WATER <br />3. ONEW CONSTRUCTION or REPAIRS <br />4.,❑ OTHER (Specify) <br />COMPLETE IF THIS SAMPLE IS A CHECK SAMPLE <br />PREVIOUS LAB NO <br />PREVIOUS SAMPLE COLLECTION DATE <br />REMARKS: <br />LABORATORY RESULTS (FOR LAB USE ONLY) <br />MPN - COLIFORM STD PLATE COUNT SAMPLE NOT TESTED <br />BECAUSE: <br />/$hoes po•+tne /m <br />MEN DILUTION TEST UNSUITABLE ❑ Sample Too Old <br />/1DO ml 1. ❑ Confluent Growth ❑ Not In Proper Container <br />ME COLIFORM <br />2. ❑ TNT'C ❑ Invdhcd—Please Read <br />/the on Promtled— Plmse Read <br />Instructions on Form <br />FECAL COLIFORM 3❑Excess Debris <br />❑ t.IPN ❑ MF 4 ❑ ❑ <br />/lee ml <br />FOR DRINKING WATER SAMPLES ONLY. THESE RESULTS ARE: <br />P SATISFACTORY ❑ UNSATISFACTORY <br />SEE REVERSE SIDE OF GREEN COPY FOR EXPLANATION OF RESULTS <br />LABN O � DATE. TIME RECEIVED— % ;& �REEMVED-D'Y'- <br />LABORATORY: <br />WATER SUPPLIER COPY J <br />7 <br />