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�5 U-193 <br />$ <br />Ocpo�lm:nt .n Servites ' <br />Heollh Servites Divisioq <br />Smilh Toweq Scoule, Waihingrol� 98104 <br />WATER BAC'�ERIOLUG�Ct��ANALY515 <br />� �� �j . � <br />NEAO INSTRUCT�NS ON BACN Of� GOLD NROD COPY <br />IF INiTRUCTI NS AREWOj PROPERLY FOLIOWFD, <br />SAMPIE WILL BE REJECTEU. . <br />FORLABUSEONLY w.-�.i�ria�io� ��i�.iai ��•�-- <br />LAB. N0. n.�� 3a/ S�� � <br />DATE COLLECTEfi ��e-xm DATE STARTED an izeaoi <br />Monih Ooy Year ���'��� <br />r <br />� � � � �� =� �i i.�_. .. <br />TIME OF DAY �so� La. NO. (Public Sprom�) COUiJTY NA/dE <br />COLLECTED p ��,� i 1311 I 1321 1311 13<I 1361 <br />_' " ❑ PM 2�_�—L -_ � � ' <br />NAME OF WATER SYSTEM . '_ CIRCLE CLASS <br />1 Y 7 4 <br />�1 —_—_-+—=----- . _ — .— <br />SYSTEM ADDPE55 ' - . � <br />.i <br />tOCATION WHERE SAMPIE WAS COIIECTED (lire smlion, school, Sth st., etc.� <br />�'� .. i.!':. ';_� :. '' � r. �- (7 <br />COLLEGTED BY: �Name) ,. <br />' /' i �-,- � , _ <br />TYPE OF iaei � O Municipol Induslrial 0 3 O Privale <br />SYSTEM � Communily °� � O Commeuial Rmiden<e <br />SEND REPORi TO: (Print Full Namc, Address and Zip Cade) <br />�i �, _ i� 't�� _ <br />i : %' ' <br />r. _ <br />/�� �• y n• 77 WASHINGTON����' �— _ <br />50 RCE TYPE �3vr Combina�ion <br />1 Q Surlam: ? Q�Nell; 3 Q Spring; 4�Purchosed; 90 or Other_— <br />TYPE OF SAMPLE �3e� ��MECK ONE ONLY) New Swimming Swimming <br />I Q Dnnkln9 Waler 4 Q ROw 3 Q Main 4O Pool 5 Q Beach <br />Sanaory <br />Wp1cr Shcllfish O�her <br />6O Svrvcy - O Seowatcr B � Srody 90 (Spedly) <br />IS TH�S SAMPLE A FOLLOW-UP TO A uei <br />PREVIOUS, NOPbCONPORMING SAMPIE? , I O Yes 0 Q�No <br />IF YES, GI�'E PREVIOUS IAB. NO. <br />�c9� SYSiEM TRSfTMENT (Check only lor Drinking Water Samplef) <br />7 Q ryan¢; 2!,j �Chlarinotion: 7 Q Filtr��lon; 4 Q Flvoridalion; <br />9 � Olhcr (Specily) _ <br />REMARKS: <br />� V�BORATORY PESULTS � <br />SEE RE`/ERSE SIDE OF PINK COPY FOR INiERPREiA�lONS <br />A. COUFORMS YER 100m1 IC FECAI COLIFORM ❑ RESUBMIT SAMPLE <br />5 TUBE MPN TEST mo� MPN Tesl Unsuhable Bemuse: <br />100m1 <br />1. �—'� 0/5 =<�.2 - nD� 1. ❑ Conllocnt Growlh <br />�ev.60�—�—E_ y.�TNTC <br />2 �� 1/5 = 21 I .. �� 100m1 <br />MF_ 3. � EKmss Dc6ris <br />3.0��1/5=SJ . � n <br />I61-fi41__�_E_ <br />4 �—� 3/5 = 9.2 <br />5. �-�—� d/5 = 16 <br />6. �—� 5/5 =>�b <br />MF ��OO�nI <br />100m1 <br />/ml <br />13].361��_E <br />❑ RESUBMIT SAMPLE n�-va� <br />Sample Rejected Bewose: (Check One Or More) <br />1. � Samplr Too Old <br />1. � Fee Nol Pmvided <br />9. O Sample Recei.ed Too lale In Week <br />4. � Inwllicicn� Informotian Pm.ided. <br />Pleose Read Inslructions On Form. <br />5. � Not In Proper Conlainer <br />6. � Lcuked Oul <br />7. 0 Other (SpeciSy) <br />5�B01 j <br />�ATE 8 TIME / ��, 17ATE � / /i �-'� I ' � <br />FECEIVED � COMPIETED � _ /1�i%�--� <br />—. � I <br />\NAItR SUPPLIER COPY <br />