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�—' DSH513t7JIR1�B1�. : � <br /> �� STATEOFWASHINGTON .��, {I l 1 � j�,�.���I <br /> j � DEPARTMENT Ok SOCIAL 11ND,HEALTM SEHVICES\.__� ��k <br /> WATER BACTERIOLOGI,CAL aNALY,SIS I, <br /> �' S;L!nlLf,�16FCl6Jq�. FLI,UI`.SIRUCT'�QhS ;;'13fiC6Q° ;1�6C'4F0��2P'i I <br /> i <br /> � If Instructlons are not tollowed, sample will B,e reJecte . <br /> � DATEGOLLECTED TIMEGOLL�T� COUN7YNAME r��i <br /> �_ � i'.: <br /> I MONTH OAY YEAP i:���. . �', <br /> ' � 7� ���� ❑ AM � � PM ' � � <br /> �I TYPE OF SYS7EM IF PUBL�C SYS7EM,COMPLETE: i <br /> �IpCIE Ctu55 � <br /> t (�j Pueuc I.D. No. � 2 3 4 <br /> I C INDIVIDUAL <br /> Iuer.ee omr�,e:�eenc.i �I <br /> II NAME OF SYS7E�t I; �.,, J ..._�__ 'L,i��� ��--, cy I <br /> �� � � � <br /> I $PECIFIC LOCATION WMEflE SPMPLE COLLECTEO SYSiEM QNNEfl/MGfl.NAME ANO7ElfPNOYE N0. � <br /> � ue.i��cre�uo�acnan.m�auoo�.iwmm�� <br /> IFG � L.C', f ,. '_li'.k' <br /> �c �I �. � ) � <br /> � <br /> SAMPLE COLLECTED BV:INamel � <br /> v=':� 1-��S%;�-S'Lu�C/C� � <br /> � <br /> I SOURCETYPE . COMBINATION � <br /> '� ❑ SURFACE ❑ WELL ❑ SPRING '�E� PUFiGNASED � or O7HER _ �I <br /> I SEND REPORT TO:�\Pi!nl Fy1�Namo.AtlS�ess e�Z�P COGe� ' <br /> ��i �lJ_, t� <br /> � -,u f�, �r �:,�:•-C'z � <br /> .� , <br /> I ' �.,C;��:C..e'--��— w it o �I�Z[') i <br /> ._ � <br /> '. TYPE OF SAMPLE (I �� <br />� 'I Ienec�oniromrin�Maco�umn� , � I - ' � '� <br /> � � ❑ Chlodnalea�Resid T lal Free ; <br /> � 1. I� �RINKING WATER ��� � � I <br /> I � I � check treatmenl� � Fllteretl ; <br />� ❑ UMreated o�Olher .............................. I <br /> �� . .... ......_... <br /> � Q, 0 RAW SOURCE WATER ""����� <br /> � 3. L� NEW GONSTRUCTION or REPAIRS CITY OF EV�� ER�� ; <br /> 4, ❑ O7HER(Specily��—RF�-• I <br /> I COMPIETE IF 7HIS SAMPLE IS A CHECK SnMPLE I <br /> I ��f%�-'•_, • �.' � <br /> I PPEVIOUS lA8 NO � — I <br /> I c.1 �'�' <br /> PFEVIOUS SAMPLE COLLECTION OATE� � <br /> REMARKS: <br />' ___- -- I <br />� LABOHATORY RESULTS(roa�ae use aN�vl � <br /> MPN�COJFORM S��'7PLA7ECOUN7 SAMPBECA SEESTED . <br /> �5wceso�s�e.c _. /ml �I <br />� ❑ Sample Too Old <br /> MPN DILUTION TEST UNSUITABIE . <br /> �00 ml �, Q Conlluent Gmw�h ❑ Nol in Pmper Conlainer � <br /> MF COLIFORM � �nsullicienl Inlormalion �� <br /> 2. CI TNTC <br /> � Provided—Please Read �, <br /> � �J �0�m� �nsirucllons on Form � <br /> �� FECALCOLIFORM 3' 0 Excess0ebris '� <br /> ' ❑ MPN ❑ MF 4. ❑ ❑ <br /> �OD ml <br /> FOR DRINKING WATER SAMPLES ONLY.THESE RESUL7S ARE: . <br /> . � SA7ISFACTORY ❑ UNSRTISFACTOHY � <br /> $EL REVEfiSE SIDE OF GPECN COPY FOP E%PLAtlATION OF RESULTS_ <br /> OATE.TIMEflECEIVED— � AECEIVEOBY � <br /> ' LAB NQ .�,��J <br /> I <br /> '� , v _ �'�:�� �.r� ;1 �� �� "i.� � <br /> :�./ �,_ ' �� i. . <br /> ; lf' � � <br />' DATE REPJR— TE—� 1A90RATORY: '. <br /> /-�� <br /> �-� �r� <br /> REMPPNS <br /> WpTER SUPPLIER COPY �' <br />