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� DSMS 11113(RL81) I <br /> � �'1 STATE OF WASHINdTQN ` � � <br /> � � / DEPAPTMENT OF SOCIAL AND HEALTH SERVICES`�_.,� <br /> ; WATER BACTERIOLOGICAL ANALYSIS � <br /> SAMPLE GOLLECTION�. READ INSTPl1CTI0N5 ON BA�K�F GOLUENROD COPV � <br /> . If instructions are not followed,sample wil�be reJected. I <br /> '' Mo HpTE CO AYECTED A TIME COLLEG7ED COUNTY NAME I <br /> �. _�'� � ❑ AM . ❑ PM -�'^� <br /> � IF PUBLIC SYSTEM C MPCETE -'� �.' .� I <br /> ' 7Y�.EOFSYSTEM � � <br /> ,ZiQCIE ClRS$ <br /> � �1�rueuc I.D. No. ,. , ' �2 3 a I <br /> �, ❑ INDIVAUAL i'..� ':� r . . <br /> � iao.es omr��es ee�ce� �y�_ <br /> ��� NAMEOFSYSTEM . }�v� � '. ��� <br /> i ! I-� � . .' . I <br /> l o� � �� ' ,� ` ' <br /> ' SPECIFIC LOCATION WHEflE SAMPLE COLLECTE�SYSiFM WINiF/MGy.41FM�ANOIElEPNO��E NO.,' <br /> i � nekecqenmoaacnooti�,eaiaua�.ia,nu��i � '-! ' \ i� " <br /> � 1, � Y-•� �� �. `_��1:�"�.A ��a ' •' <br /> r <br /> � � � 1 <br /> . � SAMPLE COLLECTED BY:INamel i �� � , � � I <br /> � ����1`T"�T�,�� �!�': . , <br /> I I <br /> SOURCETYPE <br /> COMBINA710N <br /> I' ❑ SURFACE ❑ WELL ❑ SPRING r�PUFCHASED � orOTHER <br /> I <br /> SEND REPORT T¢�V�IntFpll Name,neCreas antl 2ip CoOe) � I <br /> %+�. F-�� �c-rS-L.r�- l: � <br /> � <br /> �� '.":v=T.-- �' � �i7r'c;�_ '� � � <br /> I � `J 1 WASHIN�TON��7{�� I <br /> � TYPEOFSAMPLE i <br /> i itna�omycnei mnm��mm ' � <br /> i <br /> �, � DRINKINGWATER � �hlodna�edlResiduaC_Total_Free) I <br /> check treatment� � Filtered <br /> ❑ Unlreatetl or Olher_ <br /> � 2. ❑ RHW SOURGE W.47ER <br /> i3.;� NEW CONS7RUCTION or REPAIRS <br /> 4, O OTHER ISpeclly) <br /> � COMPLETE IF THIS SAMPLE IS A CHECK SAMPLE <br /> � ppEV10US lAB NO <br /> I� PREVIOUS SAMPLE COLlEC710N DATE — <br /> FEMARKS: <br /> i I <br /> I — — I <br /> i � LABORATORY RESULTo(Fos�ae use or+w1 <br /> i MPN�COLIFORM STD PLATECOUNT SAMPBEC USEES7ED <br /> . �5w�soos�u�� �ml <br /> � J C TE57 UNSUITABLE � � Sample Too Old <br /> � MPN DILUTION �_ i <br /> � �00 ml �, ❑ �onlWent Growlh ❑ Not in Pmper Gontalner <br /> � MF COLIPORM 2 � 7NTC � Insulliciont Informalion ��� <br /> �00�ni Providetl—Please Reatl iI <br /> Inslmctions on Form <br /> FECAL COLIFORM 3� Ezcess Debris � <br /> ❑ MPN ❑ MF 4. � ❑ I <br /> �00 ml � <br /> FOR�RINKING WATER SAMPLES ONLY,THESE RESULTS ARE: I <br /> ❑ SATISFACTORV ❑ UNSATISPACTOFY I <br /> SGE REVEFiSF.SIOE GF GREEN COPY FOH E%PIAN:.710N OP HESULT3 <br /> LABNO. DATE.TIMERECEIVEO— '�' flECEIVEDBY <br /> ^-�_�:l_� ! � <br /> '� 0�) '3JJ � � <br /> '�� o �v9� �� �' '�-;r�_� / �� �, <br /> , _ <br /> �ATE REPORTED / �' LABORATOIiw' i, <br /> #lN � / 'T ! <br /> � �� ,_ � <br /> pEMARKS <br /> Wf.TER SUPPLI'cR COF'Y °�' '� <br />