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1401 PALM AVE 2016-01-01 MF Import
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1401 PALM AVE 2016-01-01 MF Import
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Last modified
2/24/2017 9:57:01 AM
Creation date
2/24/2017 9:56:44 AM
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Template:
Address Document
Street Name
PALM AVE
Street Number
1401
Imported From Microfiche
Yes
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� DSNS q4iJ�RLBt�� <br /> � �� <br /> � STATE OF WpSHINOTON • � � <br /> � <br /> OEPARTMENT OF SOCIAL AND HEALTH SENVICES . <br /> � WATER BACTERIOLOGICAL ANALYSIS j <br /> .. .Y�16 � "'.I I f�7'�Oh Hpfdi �GSfRU�' 0;S '.�7 Pdb: �li �d�.l L�':HOL fh�.:' � <br /> � If instructlons are not foliowed, sample will be reJected. , <br /> i <br /> i DATE COLLECTED TIME CoLLECTF.p. COUNTY NAME � <br /> , MONTH OAV YERR �C� . � 5 ii <br /> i,� .:>�. �'r �pM ❑PM `; ..�:� h <br /> ; TYPE OF SYSTEM �F PUBUC SYSTEM,COMPIETE: <br /> �PUBLIC tiett[ciass ' � <br /> ❑ iNomoun� I.D. No. i z 3 a I <br /> � uvm m�r��mma.� � N <br /> ; NAMEOFSVSTEM , � <br /> ' ��� � � � L= �r�= �- tf_ , <br /> � <br /> ' SPEQFIC LOCAiION WNE E SAMPLE tOILECiED S�'S1Eh7 USMEF/MGR WIME N1�IIlEP10NE N0. � <br /> I Mn��p A f�ool.lqe\lal�m.�OunlVnl. <br /> ��Fll�ot .f� f�%:� .., ,-}�.e /�� o � � .�r.rnh- ' <br /> ; ( i � � <br /> =t_�- � €-?i C_" �, <br /> I ~ � <br /> SAMPLE COLLECTED BY:INamel � <br /> _� G �bE�J v,., �, „ �� � � <br /> SOURCETVPE <br /> I ❑ SURFACE ❑WELL COMBINATION I �-3 <br /> ❑ SPRING ❑ PURCHASED Q� � <br /> or OiHER <br /> ' SEkD R RT T1O:�Prinrl Full Name,�E�rosf anE 2' COCe) � <br /> l\�I U"� C. J(��l" � - 1�i.�">iH ' J1 � r <br /> p M <br /> , i—� t'� � •'r � - �.! _.. � , [b�' � <br /> ( V(�: �l IT� WASHINGiON �' � ��` I M H <br /> �� TYPE OF S�MPLE i � � <br /> � 6�«�o�4wminncawm� '� <br /> � � � � <br /> 7. ❑ ORINNINGWATEP ❑ Chlorinatxl�Res�dual:_Totel_Free) � <br /> i c�ecM Irealmenl—� ❑ Fillere0 � <br /> H <br /> ❑ Untreale0 or Other � <br /> '. Z. ❑ W SOURCE WATER � � <br /> �� 3. �EW CONSTRUCTION ar REPAIRS I <br /> 4. ❑ OTHERISpecily) N <br /> COMPLETE IF iH15 SAMPLE IS A CHECK SAMPLE I ([[[7''''''!!! <br /> , PPEVIOUS lA0 NO � ' � <br /> , PREVIOUS SAMPLE COLLECTION DATE � <br /> � REMARKS' � <br /> �n ...��P �i � � <br /> � � � LABORATORY RESULTS Ison��e use oN�ri � "�y <br /> i.irn�i.UiiFORM� STD PLA�E COUNT SAMPLE NOT TESTEO � V1 <br /> /� BECAUSE. I <br /> ' �S�w.w+n... . <br /> �, MPN DILUTION TEST UNSUITAOLE ❑ Semple Too OIO � � <br /> � n <br /> ��^" 1. � Conlluenl Growlh ❑ Noi in Pwce�Comalner � � <br /> MFC FORM � <br /> 2. � TNTC � InsulGclent Inlormatlon <br /> �pp m ProvlEeE-Please ReaO <br /> Instructlons on Form <br /> FECAL COLiFORM `�• ❑ Excese De�ris i <br /> ❑ A1PN ❑ MF 4. ❑ � I <br /> �Da mi <br /> FO URINKINGWATERSAMPLESONLV.IHESERESULTSARE: <br /> �SATISFACTORY ❑ UNSATISFACTORV � <br /> . UB N� �� `l O,` DRTE TiME PECErvE�- �j :;" NECENED BY ' <br /> V V � <br /> �' �n �� )�� �J � <br /> �i �i• 'i J�T.' f__� ..�1%'r ) <br /> �,��[ER/EWRt/Ej,l ♦BORATORY: 'T <br /> �,�� I�',/��[J 7 n� ' <br /> REMARItS• <br /> �'�r't i�.�. . , �i��P�.^ i..:l•pv Pi � <br />
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