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r <br />05H513,1731n 0-771 <br />••�. Stale of Washington <br />Department of Social andl4dllh Services <br />r Health Servicrs Division <br />Smith Tower, Seattle. Washington 90104 <br />WATER BACTERIOLOGICAL ANALYSIS <br />READ INSTRUCTIONS ON BACK OF GOLDENROD COPY 40 <br />IF INSTRUCTIONS ARE NOT PROPERLY FOLLOWED, <br />SAMPLE WILL BE REJECTED. <br />R LAB USEONLY ICO:-CLLY_e!lm 1a 1.1u <br />B. NO. U, 'i,.;juu <br />VA It LVLLCL.I CU ne 301 YAIC)IAKICD Ix)1 130 ,a1 <br />Dov year <br />TIME OF DAY ieei I I.D. NO. (Public Systems) COUNTY NAME <br />COLLECTED 0Al4 uu uxi u3i un u51 <br />❑PM: <br />NAME OF WATER SYSTEM CIRCLE CLASS <br />1 2 3 4 <br />SYSTEM ADDRESS <br />LOCATION WHERE SAMPLE WAS COILECTE0 Uire dation, school, 51h 31., etc.) <br />COLLECTED Bl': tNamel --- <br />TYPE OF ue1 CD Municipal Industrial Private <br />ISYSTEM Community or 2 O Commercial or 3 O Residence <br />SEND REPORT TO. iPnnt Full Name, Address and Zip Code) <br />WASHINGTON <br />SOURCETYPE m1 <br />Combinaeun <br />10 Surface: 20 Well: 30 Spring 40Purchased. 90 or0lher <br />TYPE OF SAMPLE 1081 'CHECK ONE ONE N°,A, Swimming Sw�mmog <br />1 O DrioLi ng Woler 20 IRyaatei 3 Mnm40 Pod 50 each <br />Samrary Shellfish Oiler <br />60 Survey 70Seawarer eO Smdy 9O ISpeofyl <br />IS THIS SAMPLE A FOLLOW-UP TO A um <br />PREVIOUS. NONCONFORMING SAMPLE? - - 1 O YesCON, <br />IF YES, GIVE PREVIOUS LAB. NO. <br />,eat SYSTEM TREATMENT iCheck oNy for Dnnkmg Writer Samples) <br />1 O None: 2 O Chlonneaoo 3 O F.11aron; 4 O Fluoridmwn <br />9 001her 6neofyl _ <br />` LABORATORY RESULTS <br />SEE REVERSE SIDE OF PINK COPY FOR INTE ZPRETATIONS 411111 <br />A. COUFORMS PER 100ml <br />C. FECAL COLIFORM <br />❑ RESUBMIT SAMPLE <br />5 TUBE MPN LEST uo1 <br />/IOOmI <br />Test Unsociable Bemuse: <br />1 ❑ —� 0/5 -e2.2 - <br />MPN_ <br />nm 1. ❑ Caniluem Growth <br />l e,em _ • E _' <br />2 ❑ TNTC <br />3❑� 9/5=5.1 <br />ME /1DOMI <br />3.0E.cess Deb,., <br />le 1.au _ . E <br />4 ❑ <br />4.❑� 3;5=9.1 <br />_ _ <br />❑RESUBMIT SAMPLE <br />5 ❑— 4 5 = 16 <br />,3, <br />Sample Rejected Because: IChCned One Or More. <br />6❑-- 5/5=116 <br />I. ❑Sample Too Old <br />MF /100ml <br />2. ❑ Fee Not Provided <br />3. ❑ Sample Received Too Late In Week <br />MPN DIN. TESTS <br />4. ❑ Insufficient Information Provided. <br />/ 100 ml <br />Please Read Instructions On Farm. <br />_E_ <br />5. ❑ Not In -Proper Container <br />3. STD. PLATE COUNT <br />6. ❑ Leaked Out <br />7. ❑ Other ISpecifyl <br />ml <br />its sm_ . _ E <br />REMARKS: <br />J <br />no-em J <br />DATES TIME - I1 `+U �// RECEIVED COMPLETED <br />WATER SUPPIIER COPY <br />