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nsNsu-iro�nia�� j <br /> � <br /> STATE OF W�SXIMOTON � <br /> � DEMIITMEM OF QOCIAL AND NFALiN SEIIVICEf i <br /> WATER BACTERIOLO(31CAL ANALYSIS <br /> 5l+MPLE COLLEL110N FEAU iN57RUCTI0N5 ON B0.CK OF GOI�FNNOD COPV <br /> If instructfons are not followed, sample will be rejer,ted. I <br /> ORTE COLLECTED TIME COLLECTED COUNTV NAME ! <br /> MONTN O�Y YEAR - ! I <br /> onM � nPM j <br /> TYPE OF SYSTEM �F PUBLIC SVSTEM,COMPLETE: <br /> ❑ rueuc I.D. No. `�p`" <br /> ❑ INDIVIDUAL � 3 <br /> . .ua'�cei <br /> NAME OF^SYSTEM <br /> (.. � �, f : ��/_ L��. G <br /> ��-..� . <br /> SPECiRC�DLn1lON WNEPE SANPL(COLLCCIE SVSiEM WMFP/MSP N4ME6M17E1ER10NEN0 <br /> �����I�Mnl�p m 4M»I.1 �I�I�on.I�nnl�inl . <br /> - .� . . ;, � � '�`� <br /> SAMPLE COLLECTEO BY:I�+ame� I <br /> � I <br /> SOURCELYPE <br /> ❑ SURFACE ❑ WELL ❑ SPPING � PURCMASED G COMBINRTION � <br /> a OTHER <br /> SEND REPORT TO:Ivnm Wu Name.naa�esa nne Zio C«b1 � <br /> W�SHINGTON �' � '� I <br /> iYPE OF SRMP^E I <br /> �r,n.����rvr,••.�� n u.wm.� <br /> � I <br /> 1. ❑ ORINKMG WAfER ❑ Chbrinaletl�f7esitlual'_Tolal_frlel I <br /> �heck Ireatment—� Q F111ered I <br /> ❑ Unlrealed or Olher . <br /> Z. � NAW SOURCE WATER I <br /> 3. �'NGW CONSTRUCiION ur REPAIRS I <br /> 4. ❑ OTNER ISpecily) 1 I <br /> i <br /> COMPIETE IF iHIS SAMP.E IS A CHECK SAMPI�E' l� � <br /> VNI J'OI IS I A9 NO <br /> J <br /> PRFVIOUS SAMPLE COLLECTION DATE �i��� � � S 104� � <br /> RCMARI(5: � <br /> LABORATORV RESUITS IFo e us.....q.. ... .. �`...................Y i <br /> ................. Ni .. - <br /> ' h I <br /> MPN�COLIFORM STD PLATE COUNT r�SAMpLENO��TES'TEIS I <br /> dECAUSE: <br /> /g,�.. .. �m�. . <br /> MPNDIWTIUN TESTUNSUITABLE ❑ SampleTooOIC <br /> �����"" 1. ❑ Conlluent Growth ❑ Nol In Proper Conlainer <br /> Mf�ORM <br /> 2. ❑ TNTC � Insulliticnl lnlormabon <br /> /��p.�� Pwvi0e0—Please Reatl <br /> � . Instruclions on Form <br /> FECAL COLiFORM 3. ❑ E.cess Debris ., <br /> ❑ MPN ❑ h1F 4. ❑ ❑ <br /> ��OJ mi <br /> , FOR DRINKING WATER SAMPtES ONIY.TNESE FESULTS ARE. ' <br /> �J SATISFACTORV ❑ UNSATISFACTORY , <br /> SE REVERSE SIDE OF GREEN COPV FOR E%PLANAiION OF RESULTS � <br /> LAq� ��'} u DATE TiME RECEIVED— RECEIVED BY <br /> y�- <br /> � ` �s� 7 �n- �� � <br /> ' D41E/R cORT l<90MTOAY �� <br /> I! ` 1 <br /> REM RNS , '.I �i <br /> � � <br /> ! <br /> WATER SUPPLIER COPY � <br />