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- - LSnS>>t;J J��-n'� <br /> � � "'� STpTEOFWASHINGTON ' ' <br /> ' OEPAPTMENT OF SOCIAL ANO MEAITH SEPVICES�' <br /> WATER BACTERIOLOGICAL ANALYSIS <br /> SAMPLE COLLECTION: RFAD INSiRl1CT10N5 ON BACK 0` GOLDENROD COPV <br /> II insiructions are nol lollowed, sample will be rejected. <br /> O�TE COLLECTED TIME COLLECTC-D COUNTV NAME <br /> MONTH DAY YEAR '� <br /> ❑ AM ❑ PM <br /> � TYPE OP SYSTEM IF PUBLIC SVSLEM.COMPLETE: <br /> i ❑ PUBLIC CiauE G1a55 , <br /> ' ❑ INDIVIDUAL I.D. No. �. z 3 .� <br /> u..nn u�q i�nme�<q � <br /> NAME OF SVSTEM <br /> ' $PECIFlCLOCA710NWHERESAMPIECOLLECiCD5Y5iCMUNt:FA/MGP.IJAMCAN�(ELFR�ONENU <br /> i���iw�un u.�m.n.are.�.uon�wmu�� <br /> '. . . . - . , .� (�� � ._ . . <br /> � <br /> SAMPLE COLLECTED BY:�Name� , <br /> SOURCETYPE <br /> ❑ SURFACE ❑ WELL ❑ SPRING ❑ PUHCNASED [1 'OMBINATION � <br /> nr OTHER <br /> SEIlD REPORT TO:IPriM F u ama,p{p�y eas an0 Z�0 CMe� �. /r . <br /> � (`'-0.�Guiriq.f��.a , , <br /> � �o U ��-� h a , <br /> 'I _ � �L:l��`�- LC.-YC7CSf11NGTON�Lr�� <br /> � iYPE OF SAMPLE <br /> IGr.c�mer w���m.m��m�� <br /> 1. ❑ DRINKINGWATER � Chlo�Inalcd�Resitlual:_To�al_Free) <br /> check ireatment---) ❑ Filtered <br /> � ❑ Untreated or Olhor <br /> 2, O qAW SOURCE WAtER <br /> 3. ❑ NEW CONSTRUCiION or qEPAIRS <br /> A. ❑ OTHER(Speclly) <br /> COMPLE7E IF THIS SAMPLE IS A CHECK SAMPLE <br /> FIIEVIOUS lAB N0. — <br /> PREVIOUS SAMPLE COLLECTION DA7E <br /> REMAPNS: <br /> LA80RATORY RESULTS IFon i�e use oN�r� <br /> MPN�COLIFORM Si0 PLATE COUNT SAMPOECAUSErSTED <br /> �Sw�.co,.i�.. �ml <br /> MPN DILUTION TEST UNSUITABLE ❑ Sample Too Old <br /> �00 mi �, Q ConlWent Gmwlh ❑ Not in Proper Conlainer <br /> MECOL�FORM <br /> i � 2. � TNTC � Insullicien�Inlormaiion <br /> �—�� �00 mi Provldetl-Ple2so Pcad <br /> Instruclions on Form <br /> FECAL COUFORM 3. ❑ Excess De��is <br /> ❑ MPN ❑ MF 4 � � <br /> �MI ml <br /> FOR DRINKING WATER SAMPLES ONLY,THESE RESULTS AFE: <br /> b SATISFACTORY ❑ UNSATISFACTORV <br /> SEE REVERSE SIDE OF GPEEN COPY FOR[%PLANA710N OF RESULTS <br /> UB NO. DAtE,TIME P[C[IVEU— - - REGEIV[0 BY <br /> �,��. U: <br /> � DATE'REPORTED ` _ LABORA70RV: <br /> � — <br /> REMARNS ' � � <br /> .. � - , ._ � . < . . , � <br /> WATER SUPPLIER COPV a�+ <br />