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; osNs».na�eis�r � <br /> ' '�\j STATE OF WASHINGTON I� II <br /> ' � / DEPARTMENT OF SOCI�L AND HERITN SEHVICES`, � <br /> WATER BACTERIOLOGICAL ANALYSIS I <br /> ' �qy�,p�c r�i�E�*ION: R6�7 INSTRUCTIONS ON BACK OF GOL�ENflOD COPY <br /> � ,. It instructions are not tollowed, sart�ple will be re�ected. �I <br /> • DATE COLLECTED � TIMECOLLECTED COUNTY NAME <br /> ' MONTH +D7AV YE4R � :��_ !i^ I <br /> ��. ' Z / �� ❑ AM � PM ?� <br /> ' �{i�SYSTEM IF Pl1BLIC SYSTEM,COMPLETE: � <br /> CIAGIE CLA55 <br /> � � PUBLIC �,D. No. � � z 3 4 <br /> � ❑ INDIVIDUAL <br /> ue�.es��h��o�eeocm I <br /> � NAME OF SVS7EM <br /> /�`��T ��� <br /> '��'� SPECIFIC IOLATION WHENE SAMPLE CULLECTEO SYSTEM OWNEP/MGfl.NAME PND iELERiONE N0. I <br /> I <br /> I� .ry.�ncnsn nq m xU�ooL�u.auuon.mmimm , . I <br /> � � � [:�.U.1� r1G✓'� � � .. <br /> l <br /> SAMPLE f.OLLECTED BY:INamel <br /> � ��Y_c`a—�-�,..��� ' <br /> SOUFCE 7YPE (;OMBIN 4TION <br /> ❑ SURFACE ❑ �"1ELL ❑ SPRING �P�RGHASE� �� or OTHE�. <br /> jSEND REPORT TO:1{'d��Fud Name,A/ems�ie 2ip GOEeI <br /> � � j�\ ltc: --�' 1 ' <br /> � j Gl�'. � �.-� �"ci:-�Z �, <br /> i f-� �- � y�, <br /> � �YASNINGTON I <br /> 'I TYPEOFS�MPLE I <br /> Icnec'anq mio�zcoNm�1 <br /> 1. � DRINKINGWA7ER � Chlorinated(Resldual:__Total._Free) <br /> Ic�ack trealment--) � Filleretl � <br /> �I � Untreated or Olher <br /> � 2.r��i RAW SOURCE WATER <br /> �� 3..-C_I NEW CONSTRUCTION or REPAIRS <br /> � 4. ❑ OTHERISpecily) � <br /> � COMPLETE IP THIS SAMPLE IS A CHECK SAMPLE <br /> j PflEVI0U5lABN0 <br /> I PREYIOUS SAMPLE COLLECTION DATE _ <br /> � <br /> � PE�IARKS: <br /> I _ = _-- � <br /> i� LABORATORY RESULTS IFon�ae use or+�v� <br /> ��. MPN�COLIFORM STO PLATEGOUNT SAMPBECA SEESTED � <br /> � �5 woe�no:e�m /m� I <br /> — � Sample Too Oltl � <br /> ' MPN G!LUTION TEST UNSUITABL I <br /> �_ <br /> �I90 ml �. Q �onlluent Growlh ❑ No�in Proper Container � <br /> . MFCOLIFORM 2 � TNTG � InsuHicienllnloimation I <br /> � �00 mi Pmvitled—Please Read I <br /> Instmctions on Farm <br /> � FECAL COLIFORM 3� E�cess Oebris � <br /> ❑ MPN ❑ MF 4 � � � I <br /> �00 ml <br /> FOR DRINKING WATER SAMPLES ONLY,THESE RESULTS ARE: <br /> . ❑ SATISFACTORY ❑ UNSATISFACTORY <br /> �rr �EVFFSf.GIGF OI" Gf7EF'!COPI'FOIl CvPL��NATION OF 19ESUL75 <br /> LABNO.�'7�Q/�/� �A7E.TIMERECEIVEU— RECEIVED,BV <br /> / __'_�c) C� <br /> I U U `+�J `! /_�,� -;i�C� ;�I�.' � <br /> , <br /> DATEREPORTED LA90RATOR`: i <br /> � �_����r��;�,� �� � <br /> REMARICS <br /> � <br /> W/1 i.`:i' $�i.-PI):ji f�.n.f'Y J'� I <br />