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; <br /> DSH5��34]07BYA11J.. <br /> � ,�a� .��•- /^� ��"7' '' : <br /> � (/ �) STATE OF WASHINOTON �� ��1'��� /� �j yl' -, � <br /> ��J UEPANTMENT OF SOCI�L ANU IIEALTH'�SEflVIE�3�.y/"'� .�J � ; <br /> WATER BACTERIOL.OGICAL' ANAL-��SIS a`�� �-,; <br /> S�A1FLEl:L�LF��10:'. rlE��� l'�alF7Ci,G��-0N.g�l,i��� �h�I:P�f) (�P°,�v � <br /> I If InstrucUons are not tollowed,,sampfex+ill be�re�ec�' , � I <br /> MONDH TE C DAYEC7ED EAq TIME COLLECT��p COUNN NAME <br /> f : `f`i. �_ <br /> ' Zr�I YL� ❑ AM iC] PM %���'"� <br /> TYPE OF SYSTEM �F PUBLIC SYSTEM,COMPLETE: <br /> CIRtIE C1A55 <br /> I � PUBLIC I.D. No. � 2 3 4 <br /> ❑ INDIVIDUAI <br /> uw..a o�ir��e.m�n�ei <br /> NAMEOFSYSTEM � n {(�. I�7�..P <br /> I C_ C,(� �-,..�.,-"". � f F V <br /> I `.-- <br /> ISPECIFICLOCAiIONWHEflESAMPLEWLIECtE0�SV5iEMONNEfl;MG�7.NAMEPNIIiE��c,'Q„ � <br /> ��[.\il<Mn1i01(SC�WI.IbCSULOn.IWnlilnl I 1p U <br /> i� = Z � � <br /> i f�.v.. 1�. 1 ��� ;Za� -� � � p p <br /> SAMPLE COLLECTED BY:INamel ���J�U <br /> I /���. ^'r"n3C'i..J r i �i , . . � <br /> ("�;�= � <br /> i .....� <br /> I .............. f1C r���,E� <br /> SOURGE TVPE C�,T�YCORIBI I <br /> ❑ SURFAGE ❑WELL ❑ SPRING � PURCHASED u <br /> I Pnb°fc°WbFks Deo� <br /> . SEND REPORT TO:�lPrltiLFull Ha.ne,ntlEress anE Zip Coee; <br /> h.. �.d[:.� , �-.�.. i(..� t, <br /> I -;� I <br /> i � c�CJ�.� <<�I��GL. <br /> I — � �yy+� i <br /> �-J"!_��?���'� WASMINGTON "—'�U I <br /> I TYPE OF SAMPLE � <br /> iGnM±omy o�e�n m�x cowmn� i <br /> 1, 0 ORINKINGWA7ER � Chlodnatetl(Residual:_Total_Frea) I <br /> check treatmenl--� ❑ Flltered � <br /> ❑ UntrealetlorOther — <br /> 2, ❑ RAW SOURCE WA7ER I <br /> 3.� NEW CONSTRUC710N or REPAIRS � <br /> 4. � OTHER(Specily) <br /> � <br /> COMPLETEIFTHIS MPLE,IS�C CKSAMPLE <br /> �;-�-� r -�i I <br /> PPEVIOUS I AB NO '/z.7/�� <br /> PREVIOUS SAMPLE COLLEC710N OATE j <br /> REMARKS: <br /> I <br /> i <br /> 1 <br /> i LABORATORY RESULTS 1Foa iae use or+�vl I <br /> i <br /> i MPN�CO�IFOFM S7D PLATE COUNT SAMPaECA SEES7ED i <br /> ii <br /> �i �5 mm.nmm.� �ml . I <br /> � ❑ SampleTooOld <br /> �' MPN DILU710N 7EST UNSUITABLE ' <br /> � �00 ml I <br /> . 1. ❑ Conlluenl Gruwth ❑ NOI in Pwper Container i <br /> � MF COLIFORM '� <br /> ' � 2. ❑ TNTG � Insufficienl lnlormation <br /> �� �OOmI Provided—PleaSeReatl I <br /> Inslmclions on Form i <br /> �� FECALCOLIFORM 3• � Eacess7ebris � <br /> I ❑ MPN ❑ MF 4. ❑ ❑ I <br /> �OO ml �i <br /> � FOR ORINKING YVATER SAMPLES ONLY.7HESE fiESULTS ARE: �. <br /> p SATISFACTORY � O UNSA?ISFACTORY � <br /> I ' <br /> SEE REVEASE S�DE OF GREEN COPY FOR E%PLANATIJN OF RESULTS <br /> I� <br /> LAB NO. �RTE.T�ME REGEIYEU— , �" RECEIVEO BY �. <br /> '� ,IG� D�J (r^D _.- ,!� � i � % <br /> �. pATE REPOPTED , ) LABORATOPY: " � <br /> � ! / I�; � <br /> I' / �tl� /1�4^ '� , <br /> REMARKS <br /> WATER SUPPLIER COPY �� '�, <br /> i <br />