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DSHS 13.173 (R1,81) <br />"''S 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 />❑ PM <br />COUNTY NAME <br />TYPE OF SYSTEM <br />❑ PUBLIC <br />0 INDIVIDUAL <br />(serves only 1 resltlencel <br />IF PUBLIC SYSTEM, COMPLETE: <br />I.D. No. <br />CIRCLE CLASS <br />1 2 3 A <br />NAME OF SYSTEM <br />SPECIFIC LOCATION WHERE SAMPLE COLLECTED <br />hekitchen tap 0: school, lire station, fountain) <br />SYSTEM OWNER/MGR. NAME AND TELEPHONE NO. <br />) <br />SAMPLE COLLECTED BY: (Name) <br />SOURCE TYPE <br />0 SURFACE 0 WELL 0 SPRING 0 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 />i <br />1. 0DRINKING WATER 0 Chlorinated(Residual: Total_Free) <br />check treatment —3 ❑ Filtered <br />0 Untreated or Other <br />2. ❑ RAW SOURCE WATER <br />I3. ❑ NEW CONSTRUCTION or REPAIRS <br />4. ❑ OTHER (Specify) <br />COMPLETE IF THIS SAMPLE IS A CHECK SAMPLE <br />PREVIOUS t AB NO <br />1 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 />/m1 <br />MPN DILUTION <br />400 mi <br />M /COL1rORM <br />/100 rn <br />FECAL COLIFORM <br />0 MPN 0 MF <br />/100 m1 <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 />❑ Not in Proper Container <br />❑ Insufficient' Information <br />Provided—Please Read <br />Instructions on Form <br />FORDINKING WATER SAMPLES ONLY, THESE RESULTS ARE: <br />NQ SATISFACTORY 0 UNSATISFACTORY <br />SEE REVERSE SIDE OF GREEN COPY FOR EXPLANATION OF RESULTS <br />LAB NO. DATE, TIME RECEIVED— % RECEIVED BY <br />7 J! 1I <br />DATE/EPORTED /, LABORATORY: <br />REMARKS <br />WATER SUPPLIER COPY <br />Cds <br />