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p5R5 Il t]J IIIt H11 <br /> '1`w'� ST�TE OF WIISHINOTON ?` � ' �'i <br /> � DE7ARiMENT OF SOCIAI�ND NEALTH SERVICES <br /> WATER BACTERIOLOGICAL ANALYSIS I <br /> SAMPLE WLLECTIOM H[�0 INSiNU�'IOMS ON BACK OF GOLDENRO�COPY <br /> II Instrucllons are not Ioliawed, sample wlll be rejecled. . <br /> DATE COLLECTED iIME COLLECTEO COl1NTV NAME <br /> MONiH O�Y YE�R l <br /> U . / in" Onht ' � /. �: , ' � <br /> TYPE OF SYSTEM ( IF PUBLIC SYS7EM,COMPLETE' �. <br /> � <br /> pnCll L1A55 <br /> �vueuc I.D. No. i z a a <br /> ❑ INDIVIOUAL <br /> NAM. � .,�.�, <br /> E OF SVSTEM' '� <br /> . / <br /> . �', � <br /> SPELI(IL I OCAlION WNCRE SAh1P11 f0l I!f�I1�Sv511.M ONMEH��N NAME AN�fE1EA1(NIF NJ <br /> i�.�an�o no u s� ,..i u,..ui�o�u��„i. � . ' <br /> �'` . .' � . , \ /.". /.' I <br /> SAMPLE COLLECTED BY�.R+amm I <br /> � / _" , <br /> i.� � /: � <br /> SOURCETVPE � � <br /> ❑ SUIIFACE ❑ WELL ❑ SPRING ❑ PURCHASEfI O COMBINATION I I <br /> or O1MER <br /> SEN�FEPORT TO�IPrmi run weme ne iy���a 1�p Coeel�y <br /> / � � / <br /> �r �),� (" � ,r �, <br /> ; : - . , <br /> �'' � v . � /y , WASNINGfON� , <br /> IYPE OF S�MPIE <br /> L �^!1RWKINGWAIER � ChlatlneletllResitlual'._1ate1_Free� <br /> check IreBhn9n1--► � FIIIelBA <br /> ❑ Unlreatetl oi Othar <br /> Q, RAW SOURCE WATER ' <br /> 3., NEWf.ONSTRUCTIONarREPAIRS <br /> 4. ❑ 01HER�SpxcllYl <br /> COMPLETE IF THIS SAMPLE IS A CHECK SAMPLE <br /> Plif YiU11S I nP qU �. <br /> PREVIOUS SAMPLE COLLF.CTION DATE <br /> REMAfiKS - I <br /> LABORATORY RESULT�IFon��e use oa�q <br /> MPN�COLIFORM STO PLATE COUNT SAMPLE NOT TESTEU . <br /> BECAUSE. <br /> �5�„�.,�.,..,��,. �mi <br /> MPNDIWTION TESTUNSUITABLE � SempleTooCld <br /> �no�^ �, � Conllunn�Growlh ❑ No1lnPmperConlelne� I <br /> MF COLIFORM 2 � TNTC � Ineulbclenl Inlormallon <br /> Pmvided—Ploese Reed <br /> ��t� " Inetrucllons an Furm ' <br /> �CAL COLIFORM 3� � E.r.ese DeUrls <br /> MPN. MF 4 � � <br /> ! . ).� /,Wm� <br /> FOR ORIN INO WATER SAMPLES ONLV.TI�SE RESULTS ANE' <br /> � ❑ SpTI5FAC70RV �'I�UNSATISFACTORY <br /> SEE REVERSE SI�E Of GREEN COf'Y�fOfi fxFl.aNAT10N OF HESUI.TS <br /> l�BNO �� LY� O�TE.TIMERECEWEO— NECEIVEO�Y <br /> ��.n���� ��.� . "�� ;� (�) ._/•� � •� . <br /> O�TE REPORTEO ,f� L�BORATORY <br /> ��� <br /> OEMPRNS <br /> WATCR SUPPLIER COPY "� . <br />