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UtY�H1MGNTUFYUGI�L N E LTHSERVICES� <br /> DEPRRTMENT OF SOCI L 0 HEAITH SEPVICES ' � q ' <br /> ' WA i ER BACT GICAL ANALYSIS i WATER BACTERIQ4,0 AL ANALYSIS <br /> � / y <br /> � ' SAtAPLE COI1ECilON. READ INSTflUCTIONS ON IIACK OF GOL�ENROD COPY <br /> SdA7PLE COILECTION. fl TRUCTIONS ON OACK OF GOLDENROD COPY . II instructions are not followed,sample will be rejected. <br /> � II inslruc�ions a not I011owe0,sample will be rejecled. I <br /> MOND�EC���ECTED��� TIME OIlEC.1ED. COUNTYNAME <br /> � , "'��{IATECOLLECTED TIh'E_COLLECTED COUNTYNAME / UC./ 'U <br /> � �. 'n or,r rclr� ,//`l • ❑ PM � '�f uI� L' I I(� O��p g ILNM ' ❑ PM il-�d��/l.Als� <br /> �U :� ^� CJ) f-i..- G l �tj �7. <br /> I TYPEOFSYSTEM IFPUBLICSYSTEM.COMPLETE: <br /> TYPEOFSYSTEM iFPUBLICSVSTEM.COMPLETE: �,8'pUeLIC � e4�s5 <br /> �,.a{<,u; I.D. No. f�z 7 4 <br /> (�Pueuc I.D. No. y1 � a b INDIVIDUAL <br /> � INDIVIOUAL lu�.e.omr+�euaeMe� <br /> �u�maani�i�eveerce� � NAME OF SYSTEM <br /> NAMEOFSYSTEM --- ��G � � ' � �` S«��� <br /> CUC—zC�r i' l�i��. �2� 5�-�. C � l�crt�C � <br /> SPEQFlC IOCATION WHEHE SAMVLE COLLECiEU SY57EM OWNENIMGH.NAME 8 TELEMONE NO <br /> ' SfECIFlCIOCAT�ONWNEflESRMPLECCILECTEO SYS7E160WNEPIMGNNAME6TELEPNONENO ���,kitc�ent�p@x�ool�beebeon,lounuinl <br /> ' I�e.�ncnenuo@unool.Inefintionbunlelnl . i(� <br /> .l"t 5. /-�S��R ( ) <br /> � I � ��� ` � ��/ ' SFMPLE COLIECTED BY: � ame) /� �j(�', <br /> � SAMPLECO�LLECTED.@�': INe�I ����-�`^�• IcTI ��SC���IV <br /> �.� �F] �N `(,���G SOURCETYPE <br /> SOURCETVPE COMBIiIqTION ❑ SURFACE ❑ WELL C� SPflING �PUHCHASEO 0 LOMBINATION <br /> O�SURFACE G WFIL ❑ SPRING �URCHASED ❑ . orOTHER <br /> ar OTMEH <br /> � — SEND REPORT T IP� Full Ne AOEress enE 2� oEe� <br /> $END REP T TO:IP���Fvll Neme.AEEecss enG 2i CoEe� B � � Q� . �� \ <br /> J � �;J 2 _ � �'r�� �,YI/���GO �i�NG Z fJ�trT/' 1 <br /> �� ��/��� . �A�y'� ) �- (/V I� �"�- � 1 WASHINGTON 9��I <br /> -, '�1J '-�[ LT� WASMINGTON� — <br /> 7YPE C�SAMPLE. . � <br /> . TYPEOFSAMPLE-- � � ' � �- � � � I�eikonlyo�nln�n��cdumn� <br /> iCne �oMyoneintnucdumn� ,y� �/ <br /> 1. �DRINKING WATER �,�NorinateA(NeeiEu�l: �.Tolel�Free) <br /> � 1.�DRINKING WATER �Chlarinated(Residual: —Talal—Free) c�ech Vealrtenl � � FiltereC <br /> cM1ech trealment � � Filtered ❑.Unireat¢E or Olhe� <br /> ' ❑ Untrea�edorOther 2, � ppyySOURCEWAiER <br /> � L ., RA\750URCEWAIER 3. �IEWCONSTRUCTIONorPEPRIRS <br /> '� 3. �NEW CONSTRUCTION or REPAIRS Q, Q OTHER(Specity) <br /> 4. ❑ OTHER(SPec11Y) <br /> COMPLETE If THIS SAMPLE IS A CFIECK SAMPLE <br /> COMPLETE IF THI$SAMPLE IS A CHECK SAMPLE �,�,�-�y5 <br /> .,z 7 y� PPEVIOUS LAB NO 1 / / <br /> PBEVIOUSLABNO���- '�� \ UI O�� <br /> � �J PREVIOUSSAMPLECOL�ECTIONDATE <br /> PREVIOUS SAMPLE COLLECTION DATE REMARNS: <br /> � REMARNS: <br /> I <br /> � — �pgOqp:JRY RESULTS(FOP LAB USE ONLY) <br /> �� LABORATORY RESUITS IFon�ee use oN�r� . <br /> MPN•COLIFORM STDPIATECOUNT SAMPLENOTTESTED <br /> MPN-COLIFORM ST�PIATECOUNT SAMPLENOTTESTED �ECAUSE' <br /> OECAVSE: �S��pe�oos�u.e �m� <br /> �S�uoeeoosnrve �ml — ❑ SampleTooOld <br /> MPNDILUTION TESTUNSUITA9LE � SamplcTooOltl MPNDILUTION TESTUNSUITA4LE <br /> ��t00m1 1. Q ConlluenlG.�wlh ❑ No1lnPioperCantaine <br /> ��i00m1 1. ❑ ConlWenlGmw�h ❑ NOIInPmperComain2r <br /> MFCOLIFORM 2 � TNTC ❑ Insulficivminlm�+eSion <br /> MFCOLIFORid 2 � TNTC ❑ ��+�WGc+entlnlc�mntion rqJ , ProviCetl-P�easaRead <br /> PeoNEetL F�e+saRcad �-- ���m� InSlmctionsonForm <br /> ���OOmI InslruclionsonForm 3. 0 ExcessDeb�is <br /> 3. 0 Eacess�ebris FECALCOUFORM <br /> FECALCOLIFORM ❑ MPN ❑ IAF 4, � ❑ <br /> ❑ MPN ❑ MF 4. ❑ __ ❑ IIOOm� <br /> ��lOD ml <br /> FOR DRINKING W ATER SAMPLES ONLV.TNESE RESULTS ARE: <br /> FOR DRINKING WATER SA�7P ES ONLY.TMFSE NESULiS ARE: �SATISFACTORV ❑ UNSATISFACTOR� � <br /> �ATISFACTORY ❑ UNSATISP�CTORY ' <br /> SEE HEVERSL SIDE OF GREEN COPV FOR i:}PLANATION OF RLSULTS <br /> SEE�7EVERSESIOEOfGREENCOPYrORE%P� .�JATIONOFRESULTS �pBNO. DATE.TIMEIIEGEIVEO- RECENEDO` <br /> � r' DATE.TIMEREGEIVED- 11EL[NEDOY <br /> �.a y°�. .,� i'�� � ' r� 7'� ��� �� �',D� �� <br /> ,- -�CZ3��� i% �� : � - <br /> � CATEREPORTEb LAOORA ORY. <br /> � D� EPO�TF/ � LAOORATOfiY: � <br /> REMARKS <br /> R ARKS <br /> WATER �UPPLIER COPY <br /> , wnrEa sorruEi+ c^;r — _ <br />