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DSHS 13173 (R1.81) <br />STATE OF WASHINGTON <br />DEPARTMENT OF SOCIAL AND HEALTH SERVICES <br />WATER BACTERIOLOGICAL ANALYSIS <br />SAMPLE COLLECTION: READ INSTRUCTIONS ON BACK OF GOLDENROD COPY <br />If instructions are not followed, sample will be rejected. <br />DATE COLLECTED <br />MONTH / DAY / YEAR <br />TIME COLLECTED <br />❑AM C:1 PM <br />COUNTY NAME <br />TYPE OF SYSTEM <br />0 PUBLIC <br />0 INDIVIDUAL <br />(serves only 1 res,dence) <br />IF PUBLIC SYSTEM. COMPLETE: <br />I.D. No. <br />1 <br />CIRCLE CLASS <br />1 2 3 4 <br />NAME OF SYSTEM <br />SPECIFIC LOCATION WHERE SAMPLE COLLECTED <br />pe kitchen lap at school, lire station, lorantalnl <br />SYSTEM OWNER/MCR. NAME AND TELEPHONE NO. <br />C. <br />(r ; , ) <br />SAMPLE COLLECTED BY: (Name) <br />1 1 ! _i <`• f c ,J c / <br />SOURCE TYPE <br />0 SURFACE ❑ WELL 0 SPRING ❑ PURCHASED ❑ COMBINATION <br />or OTHER <br />SEND REPORT TO: (Print Full Name, Address and Zip Code) <br />WASHINGTON <br />TYPE OF SAMPLE <br />(Check only one In this column) <br />1. ❑ DRINKING WATER <br />0 Chlorinated (Residual: Total Free) <br />check treatment —30 0 Filtered <br />0 Untreated or Other <br />2. 0 RAW SOURCE WATER <br />3. 0 NEW CONSTRUCTION or REPAIRS <br />4. 0 OTHER tSpecify) <br />COMPLETE IF THIS SAMPLE IS A CHECK SAMPLE <br />PREVIOUS LAR NO <br />PREVIOUS SAMPLE COLLECTION DATE <br />REMARKS: <br />LABORATORY RESULTS (FOR LAB USE ONLY) <br />MPN • COLIFORM <br />/5 tubes positive <br />STD PLATE COUNT <br />MPN DILUTION <br />/100 ml <br />MF CQLIFORM <br />�00 ml <br />FECAL COLIFORM <br />❑ MPN 0 MF <br />/100 ml <br />TEST UNSUITABLE <br />1. 0 Confluent Growth <br />2. 0 TNTC <br />3. 0 Excess Debris <br />4.❑ <br />SAMPLE NOT TESTED <br />BECAUSE: <br />❑ Sample Too Old <br />0 Not in Proper Container <br />❑ Insufficient'Info .nation <br />Provided—Please Read <br />Instructions on Form <br />FORD INKING WATER SAMPLES ONLY. THESE RESULTS ARE: <br />;SATISFACTORY 0 UNSATISFACTORY <br />SEE REVERSE SIDE OF GREEN COPY FOR EXPLANATION OF RESULTS <br />LAB NO, DATE. TIME RECEIVED— RECEIVED BY <br />771.2 <br />DATE REPORTED LABORATORY: <br />REMARKS / (/I <br />WATER SUPPLIER COPY <br />