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osNs u�n m�en <br /> ST�fE OF N11f111MOTOM <br /> � OEPARiMENT OF fOC111L AND lIFALTM lEIIVICEf <br /> WATER BACTERIOLOGICAL ANALYSIS <br /> SAMPLf COLLECTION READ INSTRUCTION$ON BACK OF GOLDENN00 COPY <br /> If Instructlons are not followed,eample witl be rejeeted. <br /> DATE COLLECTED TIME COLLECTED CWNTV NAME <br /> MONTM OAV YE�p Z � �� C � 1� <br /> O ��r <br /> I v 4J J ❑ AM Ia PM <br /> TVG OF SYSTEM �F PUBLIC SYSTEM,COMPLETE: <br /> ueuc �.D. No. aar�e cuss <br /> ❑ INDIVIDUAL I 2 3 S <br /> • �i�MM�I <br /> NAME OF^SY,ITEM <br /> C-J�tz�r1_ <br /> sr[euiciocniiouaNeaEsnMr�eeoutcrm eMo,ratp�tir�+ HnrnEarmrzic�ar�xo <br /> �. .,<.���.�:,.<Kb��..,,.�,�����.,�� <br /> �S' JruJe (j.0 , � L v�,'C- <br /> SAMPLE COLLECTEO B�.INnmq " <br /> Xa � R�,�-n.�t�c�, <br /> SOURCETYPE <br /> ❑ SURFACE ❑ WEII ❑ SPRINt1 URLMASED [] COMBIN�TION <br /> or OTMER <br /> SEND REPCRT TO:iPn�� uu n ae�eea s Z�n H <br /> l� . cr,r-r�°z,,�i V <br /> "3zoo CC-ca-«v C-�r�- <br /> C-,Ic-�R�T"" W.S,����,�N `'��o <br /> Trre oF sm+nie <br /> ��,,.�.�„�m„��„����m., <br /> 1. � DRINKINGWA7FR � Ch:orinated(ResiOual:_Tot21_�Fr <br /> c�eck Irealmenl—� ❑ Flllered . � j� ����� �7 ��� <br /> ❑ Unlreatee or Olhe! '' �� �2 � iS <br /> Z. C F.. SOURCE 1NATER [') <br /> 3. NEW CONSTHUCTION or REPAIRS �I:4� I � 1 ��J�� <br /> 4. ❑ OTHERISpecily� <br /> COMPLETE IF 1H15 SAMPLE IS A CMECK SAMPLE � -��--� '� �"�'" �� <br /> _ .. ' ,� F���—���1'_I <br /> Pllf V�nIIS I nH Nil • . <br /> PREVIOU$SAMPIE COLL[CTION DATE <br /> REMARNS <br /> LABORATORV RESULTS(Foq��e use oN�vl <br /> MPN�COLIFORIA STD PLATE COUNT SAMW_E NOT TESTED <br /> BECAUS['. <br /> �5 u.., � ...�. �mi ' <br /> MPNDILU710N TESTUNSWT>BLE ❑ SampleTocOltl <br /> �Oli mi � � Conlluen�Gmwth ❑ Not In PropEr Con�ainer <br /> MF C FORM � <br /> 2. ❑ TNTC � Insullicient Ilqormat�on <br /> ������, Providetl—PI ap F.+atl <br /> InslrUctions o�j Fofm <br /> FF.CAL COLIFOFM 3. 0 Excess De0ri5 , <br /> ❑ h!PN ❑ M� 4 � ❑ <br /> __I�00,-.i — <br /> fON pRINKING WATER SAMPLES ONLY,TMESE RESULTS ARE. <br /> 1 �X SPTISFAGTORY ❑ UNSATISFACTORY <br /> SEE FF.VERSE SIDE OF GREEN COPY FOR E%PLANAiION OF RESULTS <br /> L�B NO DAiF..TiME REGF.IVEO— REGEIVED BY <br /> „ :i .> i� ., '� G) <br /> _�_& <br /> DP�E, [�, ED ,UBORRTORP <br /> J,'/C�' '. � <br /> 1FEMA NS � <br /> WATFR SUPPLIEH COPY <br />