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i.�:�c. i i�ri,u,�ii,�_ <br /> � <br /> . ` a STAiE OF WASMINOTON „ , � <br /> DEPAqTMENT OF SOCIAI ANO HE�LTH SERVICES' � I <br /> WATER BACTERIOLOGICAL ANALY£IS <br /> SMAPLL LUl I.CCl10N Rf A� INSiBUGiIONS ON Q�f.N Of fOL�ENRUD COPY � <br /> II instruclions are nol lollowed, 5ample wlll be rnjeCled. <br /> i <br /> DATE COLL[CT[0 TIME COLLECTED COUNTV NRME . <br /> MONLH D�Y YE�R � � � ' '. ' , / � <br /> i r.' 7 i � 0 AM , ❑ PM -Ji. �I• _�i�� . - , <br /> TVPE OF SYSTEM� IF PUBLIC SYSTEM,COMPL�TE'. . <br /> d PUBLIC uPn!p A$S � <br /> ❑ INDIVIDUAL I.D. No. i 7 3 4 <br /> ..,e.�..i I <br /> NAME OF SYSiEM , <br /> �t� � � __ i i - <br /> %. / ; . 'i� <br /> SPEGf IC LOCAI 10N WNI9E SAMPtE COU ECifO SVSIEM QYNCfl/MGN NAMC ANII Tf I I I1KME�M7 <br /> i� u.��.n,r.�nmiu�.e.u�inmu�ni /� — 1 <br /> • �� r ! " I <br /> � . I .et� , ii <br /> \' �� I <br /> SAMPLE WLLECTED BY'IN�mel I <br /> / . <br /> SOUNCETYPE� I <br /> ❑ SURFACE ❑ WELI ❑ SPflING ❑ PURCHRSEO [�J pOOMHIERTION . <br /> SEND PEPORT T0:IPnnl FWI N�me,�Warees uM Iip Co9p� � <br /> /.. . j <br /> � <br /> 1 <br /> —r <br /> / '- � <br /> W�SNINGiON'� i <br /> TYPE OF S�MPIE <br /> ILMr�n ���einlnifrni��nn� <br /> � .i n r <br /> 1..� DRINKINf,WATER � ��Iorinaletl�Reeldual:_Talel_Frea) <br /> chBck bxalmon�--� ❑ FII�eroU <br /> ❑ Unl�aeleU or Other <br /> Z. RAW SOURCE WATER <br /> 3. NEW CONS�RUCTION or REPAIRS <br /> 4. ❑ OTHER ISpeclly) <br /> COMPLETE IF TMIS uAMPIE IS A CMECK SAMPLE <br /> PPEV�nIIS I dA HO <br /> PREVIOUS SAMPLE COLLECTION DA1E <br /> REMARNS <br /> � LABORATORY RESULTS IFon i�e use oN�r� � <br /> MPN�COLIfORM STD PLATECOUNT SAMPLE NOTTESIEO <br /> BECAUSE'. <br /> �5eu<�r��.���.. �m� <br /> MPN�ILUTION TEST UNSUI�ABLE ❑ Snmple Toa Oltl <br /> ����'^� 1. ❑ Conlluanl Gmwlh ❑ Nol ln Propar Conlainar <br /> MF COLIFORM <br /> 2. � TNTC � Insulllclenl Inlormetlon <br /> �00 mi , / Piovlded—Plaaso Raetl <br /> FECAL COLIFORM <br /> 3 Fa�l E�ceen Da�rle �^���ucllone on Form <br /> ❑ MPN ❑ MF 4 � � <br /> �00 nil <br /> FOR ORINKINO WATER SAMPLES ONLY,THESE RESULTS ARE: <br /> ❑ SRTISFACiORV ❑ UNSATISFACTORY <br /> SF.-C RFVFFSF SIf1F.O�GHPFN OOPY fOR F%PI ANA710N Of RESUI 1S <br /> LAB NO DATE.IIME flEGEIVEO-� IIECEIVEO BY <br /> ':i,(1�1�IU <br /> /t' � I <br /> D�LE REPORIE� I�BOR�iORY � <br /> l. <br /> REM�RI(5 <br /> VIATEF SUPPLIFR COPY r, <br />