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. , osNsu�i»m�en <br /> . S�AiF OF WI1i1NMOTON i <br /> OE➢AIITMQiT OF SOCIIIL�MD IEAItN EEAVICES ' <br /> WATER BACTERIOLOGICAL ANALYSIS I <br /> SAMPIE LOLLECTION flFPD IN.iTflUC1��N5 ON BACII OF GOIOCNflOD COPV <br /> ❑ mstmctions are not tollowed,sample will be rel��ed. I. <br /> OATE COLLECTED TIME COLLECTED COUNiY N�ME <br /> MONTM ��Y YEAR � ; � �� �. <br /> �J ._}j <br /> �(.? I� �C�'j ❑ AM �'PM . . <br /> TYPE OF$YSTEM �F FUBLIC SVSTEM,COMPLETE: - �� <br /> � c.of.if CC�ASS. <br /> p-c"uauc I.D. No. � ,2 � a ,,='� <br /> ❑ INDIVIDUAL <br /> .i,.�e.�oi <br /> NAME OF S�STEM �� <br /> � �� � • ! � i i ,LK (• � <br /> $PLCIRCIOf,AiIONWHLAfSAMPLEC�LLCCTE SVSIEMO'NNFA�MGNN�MEANU7CLERIRICNO <br /> ��L�I(Mn��D b �I�.MI.l��n�tllliM.lounl�inl <br /> �, l ` <br /> t� 1 � / <br /> SAMPLE COLLECTED BY:M�mel <br /> _ �. �� . , i. � - . .. ' }, i <br /> SOURCE iYPE � / , COMBINIITION i <br /> ❑ SURFACE ❑ WELL ❑ SPRING ❑-PURCNASED � a OiHEP <br /> SENO REPORT TO:IPnm FWI Nxme,/�o0nae uM Zio Code� I <br /> i � /(•. <br /> ` 1 <br /> ) <br /> ' � � W�SMINGTON <br /> IYPE OF S�MPIE �i <br /> d.n�a�a r m.n.e�m�, m <br /> + � ^M ❑ Chlorinatea�PesldueP._To�al_Free� <br /> �. � DRINI(ING WATER <br /> cneCk beatmenl—► � Filte�?A <br /> ❑ Untreate0 or Other <br /> Q, Q RAW SOURCE WATEP <br /> $. O NEW CONSTPUCT!ON o�REPAIRS <br /> 4. ❑ O7NERISpet�lY1 <br /> COMPlE7E IF THISSFMPLE IS A CNECK SAMPLC-� ) L5 <br /> ��������.�S��A.;�, - O(`T 15 1��� <br /> PFEVIOUS SAMPIE COLLECTICN DATE <br /> REMARNS'. <br /> . . ........._._.__.._...._............................... <br /> L' I <br /> LABORATORY RESUITS IFon ,USE ONL <br /> M ' v�'.^r�<s C^L <br /> h1PN�COLIFORM ' STD PLATE COUNT SAMPLECAUSEESTEO <br /> /y,..�.,.�,., /mt <br /> MPN OILUTION r lEST UNSUITABLE � Sample Too O�A <br /> �00�ni �, Q C�n�luem Growln ❑ NOI in Prope�Conlainer <br /> MF C �FORM 2 � TNTC � Insulliciem mlormatiun <br /> ��00 m� Piovi0a0—Please Rerd <br /> Inslruchons nn Form <br /> FECAL GOLIFORM 3' � E�cess De�ris <br /> ❑ MPN ❑ MF 4 � � <br /> ��p�n1 <br /> FO INKING WATEN SAMPLES ONLV,TMESE PESULTS ARE: <br /> SPTISFACTORV ❑ UNSATISFACTORV <br /> SE�F7EVERSE SIDE OF GRFEN DPY FOR F%PLANATION OF RESULTS <br /> � DOTE TIME RECENEO— �� AECEIVEO BY <br /> LAP NO ` <br /> 7 ' 5 46 D - - 8 <br /> DATE�E RTEV L�BORRTORY. d �� <br /> �a '�� � <br /> MR MS � <br /> '� �i1PpLIER COPY <br />