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Dsr�s u v]IRbaq I ' <br /> � STATE OF WASMINOiON y"��t � <br /> ` � DEPANTMENT OF SOCIAL AND MEqLTN SEPVICES �� <br /> WATER BACTERIOLOGICAL ANALYSIS <br /> SAMPI.i COLLECiION REAO INSTHUCTIONS ON BACR Of GOLOENBOD COPY <br /> — If instrucllons arc not lollowed,sampie wlll be re�eclod. � � <br /> I <br /> OATE COLLECTF� TIME COLLECTED COl1NTY NAME � <br /> MONiH DAY YE�R �' > _ <br /> �1� <br /> /'�� : / •�J •,� ❑ AM . � PM %i . � ..I, � <br /> TVPE OF SYSTEM �F PU�LIC SYSTEM,COMPLETE: � �, <br /> ❑-PU6UC � <br /> I.D. No. ��enrn.ss . <br /> ❑ INDIVIDUAL � p � a � <br /> • .,o-. i <br /> NAME OF SYSTEM� � <br /> .�. � % / .i '�/� . <br /> S�ICIGiC i01:AilON WHCPC�SAMPIF C�Lf FI;I(�SYSIW UYryFN1MfN NAM(RN�I[f(R%7HlHU <br /> �,.�.�.n.,un � .�nmi m.���ef.,ro�mu,m <br /> , ; � ;�% , F � <br /> , �. � , <br /> . �`-" (, ; ) -� o � c � <br /> SAMPLE QOILECTED 9Y:�N�me� <br /> ��� ��.� ,% �-� —r` ,/, �'� � <br /> SOURCE TYPE, � <br /> ❑ SUHFACE ❑ WEIL ❑ SPRING ❑ PURCHpSED Q a�°oTB;ERTION - j <br /> SEND fiEPORT TO:�Prmi F�n Ne�e.�aUrm��p Do Cafq j <br /> � f „=•. - �%' � <br /> . ; � ,. r <br /> , <br /> _ „ � , <br /> � � W�SHWGiON '�F• ` �'� <br /> fYVE OF S�MPIE �� <br /> e. rmr�nm.�cm�mm <br /> ..J�. i <br /> 1. ❑ DHINKINGWATER ❑ Chlonnatea�ResiOueL_Tolel_,Frea� I <br /> checN �realment� 0 Flllaretl ' � <br /> ❑ Untreeletl or Olher I <br /> 2. O RAW SOURCE WATER <br /> 3.EJ NEW CONSTFUCTION or REPAIRS � <br /> 4. Q OTHER�SOaclly� <br /> COMPLETE IF TNIS SAMPLE IS A CMECK SAMPLE <br /> ��ni ViOUS i nP NO <br /> PREVIOUS SAMPLE COLLECTION�ATE I <br /> REMAqKS <br /> I <br /> LABORATORY qESULTS�Fon ue use oN�r� � <br /> ,���COLIPORM STD PLATE COUNT SAMPLE NOT TESTED I <br /> 5 BECAUSE: <br /> �ml <br /> MPN DILUTION • 7EST UNSUITABLE ❑ Semple Too Old <br /> ���'"' 1. Q Conlluenl Growlh <br /> ❑ Nol In Proper Contelner <br /> � MFCOLIFOBM � <br /> 2. � TNTC � Insulliclenl lnlormalion <br /> �un nn Pm�itlatl—Pleesa Reaa <br /> FECAL COLIFORM <br /> 3. ❑ Evicese Do6rlq ��slmctlone on Form <br /> � MPN Q MF 4. � ❑ � <br /> � 100 ntl <br /> FOR OBINKIN6 WATER SAMPLES ONLV,THESE FESULTS ARE' <br /> ��3�SATISFACTORY ❑ UNSATISFAC70RY <br /> S[E Rlbf'NSF SIDf u�,NFfN COPY f0�1 E%PLqNAiION OF RFSUI]S <br /> L�8N0 O�TE.IIMERECEWEp— <br /> ,,,,,���I� ��'�, REGEIVED 9Y <br /> `�� ,�) _ 1: �105 � J +.� . <br /> � � C� ' '������ I <br /> OATEPEPOqTEO . I�BOR�iOPY: � <br /> r- -iY/� I <br /> :�-i,�„ <br /> REM�FNS <br /> / . � f.." _. __ i <br /> wnrrn surrurn c,nPv � <br />