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prJP; i� .�a..n� . <br /> � - � STATE OF WASMINOTON � , I <br /> � DEPARTMENT OF SOCUL AHU MEALTM SERVICES <br /> WATER BACTERIOLOGICAL ANALYSIS <br /> snr,+riE coi i EcnoN nrnr ir�srHucnor.s o�e.,ck o� coi_oeNFlon conv <br /> If Inslrucllons are not followoQ sample w�ll be ro�ected. , <br /> i <br /> �ATE COLI ECTED TIME COLLECTED COUNTV NAME ! <br /> MONTH DAY YEI.R ,� ' '� <br /> � <br /> � � , ,• ,O AM ❑ PM - � '� �� , :1/)� � i(�. i <br /> TVPE OF SVSTEM �F PUBLIC SYSTEM,COMPLETE' l� <br /> O rusuC I.D. NO. onn�cuss I <br /> ❑ u+owieun� i 2 a a <br /> • .,,a.��.� � <br /> N�ME OF SVSTEM ' <br /> /�. . ' . . _ � ✓ . � <br /> SPIC IC IOCAlION WNFPE 6AMPl( LUILECfEU SYSiEMONNFP/MGN HAMEPNf1IFlfiMIWE NO <br /> I�n ��1[Mn lap I 1<Mu�� 1 ��I�I�on�MA���n� . I <br /> - / .,/, ,. / . l.— <br /> ,- � <br /> � � <br /> SAMPLE COLLEGTED BY:IN�mel — <br /> �• " <br /> SOUHCE TYPE <br /> ❑ SURFACE ❑ WELI ❑ SPRINO ❑ PURCMASEL ❑ COMBINATIpry i <br /> or OTMER <br /> SEND REPpRT TO:IPnnl Fun Nupe.�aoreee�na z�p Caae� I <br /> �•_ �]- <br /> � , i <br /> � ' , I <br /> W�SHINGiON ' � " � '� <br /> iYPE OF SAMPLE i <br /> L•� DRINNINGWATER � C�IorinnleU�ReslEueC_Tatal_Free) I <br /> chnck Irealment—� ❑ Filtoratl <br /> ❑ Unlrealad or Olher <br /> Z. ❑ RAW SOURCE WATER � <br /> 3_� NEW CONSTRUCTION o�qEPAIRS <br /> 4. � OTHER�Specllp I <br /> COMPLETE IF iM15 SAMPLE IS A CHECK SAMPLE i <br /> i <br /> Plq yi0II5 1 nfl NU <br /> P{7EVIOUS SAMPLE COLLEC710N OATE <br /> _ HEMRflKS�. ' <br /> � LABORATORY RESULTS IFon ue use ornr� <br /> MPN�COLIFORM STD PLATECOUNT SAMPIE NOTTESTED <br /> /n BECAUSE: <br /> �5�.� .�.,,��..� <br /> MPN OILUTION�' TEST UNSl11iABLE -� � Semple Too 010 <br /> �OOmI �, Q ConllunnlGrowlh ❑ No1lnProperConlalnar <br /> MF WLIFORM <br /> 2. � TNTC � Insulllclent I�lormallon <br /> �OOmi ,(�i-� ProvltleJ—PleaeaReetl <br /> FECAICOLIFORM <br /> 3/L-I E.cese Dabils Instmclions on Form <br /> ❑ MPN ❑ MF 4 � ❑ <br /> �Ip mi <br /> FOR DRINKINO WATER SAMPLES ONLV.THESE RESUL75 ARE: <br /> ❑ SAiISFACTORY ❑ UNSATISFACTORY <br /> SfF qHVP{�S!'iI�E OF�RFEN COPV FOR[%PI.�NA'ION OP RG5111 t!: <br /> UBNO O�iF,TIMEREGEWE0. �' -- q[g[ryCDqY <br /> '!f�U��'i l�:`� "� <br /> �i� , ^;� . <br /> pATf qEPORTED L�BORAiORY <br /> REMRRNS <br /> wnrrr� sua�u�_a corv ,,, <br />