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N1 <br />- OSM$IJ.I)J In ea)I <br />State of Washington <br />Department of Social odd Hepllh Serrm <br />Health Snri<es Oiriuoa <br />.1 Smith Tower, Searle, Washingon 98104 <br />WATER BACTERIOLOGICAL ANALYSIS, <br />READ INSTRUCTIONS ON BACK OF GOLDENROD COPY 40 <br />IF INSTRUCTIONS ARE NOT PROP0LY FOLLOWED, <br />SAMPLE WILL BE REJECTED. <br />FOR LAB USE ONLY CO. -CITY in 1m M <br />IABYryQ. ,I-,1.,,�A �1 <br />hC'1v J✓.✓7�7 hJs' <br />DATE COLLECTED nsam DATE STARTED rzm 1:eam <br />rnomm Oav rear lzram (� <br />TIME OF DA met I.D. IF <br />Systems) COUNTY NAME <br />COLLECTED uu um 1 uv 1 un as' I , / <br />P. <br />NAME OF WATER SYSj M _/ /y� / CIRCA 3LaSS <br />LOCATION, WHERE 5AMPLE WAS COLLECTED (fire 1Ia1i0L "hoot, 51h It. .10 <br />COLLECTED OY:INa met <br />TYPE OF net Yys Municipal Industrial / Private <br />SYSTEM 1 J`i Community °r 2 O Commercial or 3 O Residence <br />SEND REPORT TO: (Print Full Name, Address and Zip Pace] <br />WASHINGTON}!' <br />SOURCE TYPE :7, <br />„( or Other <br />lion <br />10 Surface. 20 Well; 30 Spring: 40 Purchased; 9 ` or Otherr <br />TYPE OF SAMPLE 1pB1 CHECK ONE ONLY New Swimming Swimming <br />1 O Dnnking Water 20 Raw 3Moln A O Pool 5O Beach <br />Water <br />Sonnory - Shellfish Other <br />60 imyey 705oowater 8051udy 90 15pec1fyl <br />IS THIS SAMPLE A FOLLOWUP TO A um <br />PREVIOUS. NONCONFORMING SAMPLE? 10 Yes 0g No <br />IF YES. GIVE PREVIOUS LAB. NO. <br />,csx SYSTEM TREATMENT Check only far Drinking Water S°mphol <br />1 O None: 2AChlorination; 3 O finraroq 4 O Fluoridation; <br />9 O Other ISpenfyl <br />LABORATORY RESULTS L <br />111111101111, SEEREVERSE SIDE <br />OF.PINK COPY FOR INTE <br />PRETATIONS �• <br />A. COLIFORMS PER 100ri <br />C. FECAL COLIFORM <br />❑ RESUBMIT SAMPLE <br />5TUBEMPNTEST uar <br />/100ml <br />Test Unsuitable Because. <br />I. ❑ —+ 015 se2.2 <br />MPN <br />nor I. ❑ Confluent Growth <br />° <br />157 eat_•—E_ <br />/100m1 <br />2.❑TNIC <br />3.0 6cess Debts <br />5.1 <br />ME <br />• E <br />q. ❑-• 3/5 - 9.2 <br />rnl.ea _ _ —_ <br />❑ RESUBMIT SAMPLE main <br />5. ❑—• 4/5 - 16 <br />Sample Rejected Because: (Check One Or Morel <br />6.❑- 5/5=>16 <br />-1. ❑Sample Too Old -. <br />MP / I00ml <br />2. ❑ Fee Nor Provided <br />441 441 E �`) <br />3. ❑ Sample Received Too Late In Week <br />4. ❑ Insufficient Information Provided. <br />MEN DILN. TM�s <br />/ 100 ml <br />Please Read Instructions On Form. <br />E <br />5. ❑ Not in Proper Container <br />us-aer_ • — _ <br />6. ❑ Leaked Out <br />B. STD. PLATE COUNT <br />7. ❑ Other (Specify) <br />/ml <br />1s3.sei_ • _ E <br />REMARKS: <br />it <br />DATE 8 TIME - DATE <br />RECEIVED "' ./ ' / COMPLETED- <br />�Y WATERSUPMIERCOPY _� <br />NJ <br />