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�- <br />OSMS 13�1J31RB-))I <br />Depa�lm.ent o1a�:iui and NeQ��h Serviaes <br />� Heollh Servicet Uivision <br />� SmitF Tower, Seo111e, Wafhinglon; 98104 <br />WATER BACTER,{QLO�GIGA4 ANALYSIS <br />� I t � <br />READ INSTRUCTIONS; N BAC�: OF 60LDENROD COPY <br />IF INSTRUCTIONS ARE NQT YROGERLY FOLLOWED, <br />SAMPIE�WIII BE REJECTED. <br />FOR LAB USE ONLY W: c.n i ie�im �i �-iai <br />LAB. N0. ��->i . . i . . <br />�-1/.Y?il�/ �lr . . <br />� . <br />ne�e�nuertcn......, f1ATFSTARTFfI avl aa�3o� <br />Momh/ Doy / Yeor I"' `o' .. �' <br />� _ J : i: <br />i <br />IIMCV�UMi 1681 � Ireun.+�••.....r <br />COLLECTED O AN, 1 OII 1321 1331 1]41 1331 <br />�' GYM2 � ' - _ <br />NAME OF WATER SYSTEM CIRCIE—JClA55 <br />1 4 3 d <br />SYSTEM ADDRE55 � .. <br />i <br />LOCATION WHERE SAMPLE WAS �COILEQED ((i�e station, schoai, Sth sL, elc.) <br />WLIECTE08Y:'INamel .. _- � ,'� <br />TYPE OF asr O Municinol �— Industriol or 3 O P�ivole <br />SYSiEM � Community �� � � Cammer<ial Residence <br />SEND REPORT TO: (Prini Full Name, Address ond Zip Cade) <br />- , WASHINGTON ` <br />SOURCE iVPE �3'li . Combina�ion <br />7 C� Svrfoce; 2 Q Wcll; J O Sprinq; 4 Q Por<hased: 9 Q or Other <br />TYPE OF SAMPIE �3a1 �CHECK ONE ONLY) New Swimming Swimming <br />I(� Jnnking Woter 4Q Wa�� 3 Q Main 4 Q Pool 50 Bmch <br />$oniiory �Slielllish Other <br />6(.�$vrvcy 7�Seawaler B�Study 90(Spevily� <br />IS THIS SAMPLE A FOLLOW-UP TO A �39i <br />PREVIOUS, NON�CONFORMING SAMPIE? � O Yes 0 Q No <br />IF YES, GIVE PREVIOUS 1A8. NO. — <br />isei SYSTEM TREATMENi (Che<k only for Urinkine Water Somples) <br />I� None; 2 Q��hlo�inalion: 3 � Fillration; 4 Q Fl�oridalion; <br />9 Q Other (Specily) <br />� LABORATORY RESULTS � <br />SEE REVERSE SIDE OF PINK COPY FOR INiERPRETATIONS <br />A. COLIFORMS PER 100mI C. FECAI COLIfORM ❑ RESUBMIT SAMPLE <br />5 TUBE MPN TESi iaa� ��QQm� Tesl Unsoita6le Bemose: <br />MPN �pai 7, Q Conlluenl Gmwlh <br />1. ���0/5=«.2 <br />uv.sor_�_E_ 2. �TNTC <br />2.0�1/S=P.Y /100m1 <br />MF 7. 0 Eacess Debris <br />].���7/5=5.1 <br />IGI-fi91��_E_ Q. ❑ <br />a. �� a/s = va <br />5. O—� 4/5 = 16 n RFSUBMIT SAMPLE ni���� <br />Sample Rejec�ed Becovfe: (Check One Or More) <br />d��5/5=>76 �.�Sample7ooOld <br />MF /100m1 <br />/ 100m1 <br />we.ne�_�_F_ <br />/ml <br />133�361_��_E_ <br />2 � Fee Not Pmvided <br />3. 0 Sample Received Too lale In Week <br />4. D lntvf(icieN In(ormotion Provided. <br />Please Read Inslrocfians On Porm. <br />5. � Nol ln Proper CoNainer <br />6. � Leaked Ouf <br />7. 0 Other (Specily) <br />. G- � <br />' / 05�001 <br />DA7E 8 TImE _�.., f DATE %. I"'� i ./�_ r-. <br />RECEIVED '1 � ( COMPLETED � / � /� <br />t <br />WC.TER SUPPUER COPY <br />