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\_ DEPARIMENI Ur SUCIAL ANU HGAI.IN bittiMci •-,.,. <br />WATER BACTERIOLOGICAL ANALYSIS <br />SAMPLE COLLECTION: READ INSTRUCTIONS ON PACK OF GOLDENROD COPY <br />-. . <br />- <br />i <br />If instructions are not followed, sample will be rejected. <br />- <br />DATE COLLECTED <br />TIME COLLECTED <br />COUNTY NAME <br />MONTH Dt`, <br />/�/� <br />2s❑vAAMM <br />❑ PM <br />J (/ <br />_ <br />PE OF SYSIC <br />SYSTEM, COMPLETE <br />❑.PUBLIC <br />o. <br />CIRCLE CLASS <br />❑ INDIVI <br />t2 3 4 <br />. an <br />I <br />NAME OF SYSTEM <br />n ,,.r :_+�, y �� ,:• <br />• <br />' <br />SPECIFIC LOCATION WHERE SAMPLE CC[ LECTEDI <br />SYSTEM OWNER/MOII. NAMEEAAANNNDTETEEUE(ERR�(OOINNyNO. <br />(N. AIICMnt O.[I,OOL ItrULLm, hunlu'1 <br />� <br />-�—[-- <br />' <br />SAMPLE COLLECTED BY: (Nalne)_., <br />- ' <br />SOURCETYPE) - .. <br />- <br />❑ SURFACE ❑ WELL G SPRING ❑ PURCHASED ❑ or OTHERTION <br />- <br />- <br />SEND REPORT TO: IN <br />aaress and Zip Cocel <br />�"•t ? a_4 37 1}.Y�' <br />— <br />..� rYse%Y.�..Y RL.�L^��♦ <br />t,i� <br />�- WA$HINGTON <br />_ <br />._+. >'.^'�t'*"'fa-"htT,• <br />- <br />TYPE OF SAMPLE <br />ICn k mlr [.. in N [owmp <br />- <br />• <br />•1. <br />J <br />'r..% '. �-�+ ,,. ��'r r pa•p•, Yrg <br />7, ❑DRINKING WATER ❑ Chlorinatetl (Resltluah_Total_Free) <br />t� , <br />-'check <br />treatment —T ❑ Filtered <br />rk <br />❑ Untreated or Other <br />- <br />2. ❑ RAW SOURCE WATER <br />3. ❑ NEW CONSTRUCTION or REPAIRS <br />4. EF OTHER (Specify) <br />,I <br />COMPLETE IF THIS SAMPLE IS A CHECK SAMPLE <br />2 <br />PREV'JU$ LAB N0. <br />PREVIOUS SAMPLE COLLECTION DATE <br />REMAFKS: <br />LABORATORY RESULTS (FOR LAB USE ONLY) <br />I . <br />• • - -. <br />MPN-COLIFORM <br />STD PLATE COUNT <br />SAMPLE NOT TESTED <br />j - <br />- <br />BECAUSE: <br />i - <br />❑ Sample Too Old <br />- <br />MPN DILUTION <br />TEST UNSUITABLE <br />C'-1 <br />/100 111 <br />Confluent Growth <br />❑ Not In Proper Container <br />- <br />MFOHM <br />/t00 <br />2. ❑ TNTC <br />❑ Insufflclent'Informatlon <br />Provided —Please Read <br />mi <br />3. ❑Excess Debris <br />Instructions on Form <br />- <br />.... . _ <br />FECAL COLIFORM <br />- <br />❑ MPN ❑ MF <br />4, ❑ <br />❑ <br />I <br />- <br />' /t00 m1 <br />1 <br />- •� <br />FOR DRINKING WATER SAMPLES ONLY, THESE RESULTS ARE: <br />. <br />•. �, ' <br />❑ SATISFACTORY ❑ UNSATISFACTORY <br />- <br />SEE REVERSE SIDE OF GREEN COPY FOR EXPLANATION OF RESULTS <br />- <br />lL\II NO. <br />• <br />DATE, TIME RECEIVED— lI r <br />RECEIVED BY <br />l <br />DATEREP- <br />LABO AT)HY: <br />REMARK$ <br />i <br />J <br />I <br />- WATER SUPPLIER COPY-, <br />