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U5��5 U t]911it PII <br /> -"� 57ATE OF WASHINOTON r �"\ <br /> ' ' DEPARTMENT OF SOCUL�NO NE�ITM SERVICES . <br /> WATER BACTERIOLOGICAL ANALYSIS j <br /> SAMPLE COLLECTION RCAD INSTRUCilONS ON BACN OF GOLUf.NROD COFV <br /> II Instructlons ere not loltaw0d, sample wlll be rc�ocled. � � <br /> i <br /> DATE COLLECTED TIME COLLECTED COUNTY NAME I <br /> MONTN p1Y YE�A ' � � r- <br /> �� � � ❑ AM � O PM . �I �� <` � � i <br /> iVPF OF SYSTEM IF PUBLIC SYSTEM,COMPLETE: <br /> [1 PUBUC r�an! nnss I <br /> ❑ INDIVIDUAL I.D. No. � p � q <br /> �. � „m�,. I � <br /> NAME OF SYSTEM w <br /> / "' , —.. <br /> i , <br /> / ,� 1 _ l. � %/, � I�_ � ; � <br /> tiP[UfIC IULAIION WMENE$AMPI .COII(.C7ED SYSIEMIMMER/MOF NAML ANO III(RpNF HI1 <br /> li�I�It��n1�1+J�rMml I� 11�I�nn I�n1Yn� ��- , I <br /> �N_ I- , �ej*- ! ' !` (- ( <br /> f (' (' ) 'Y / '> i <br /> SA'.'PlE COLLECTED BV:INeme� I <br /> j , �� ��_ �-'_ �%/� � _ <br /> SOURCETYPE <br /> ❑ SUHFACE ❑ WELL ❑ SPRINQ ❑ Pl1RCHRSED Q COMBINATION <br /> or OTHER � <br /> SEND FEPONi T0:IPnnl Full Nune.�Jyµ��ntl 2iD CaUe� : i <br /> (' �� f'. li r% � <br /> ' ' l I <br /> ;, , � <br /> —�- "7'� ;r,� � <br /> I- � / � WASHINGTON� � � <br /> IYPE OF S�MPLE - <br /> �[bo o �n ��mn�a�mm � <br /> � ^ v <br /> �. ❑ DRINNINGWATER � C�btlnaled�Reeltlual�_Talel_Free) � , <br /> c�eck�reetmenl—► � F�Ilered �� �i <br /> ❑ Untrxetad or Olher ' ', <br /> Y. ❑ RAW SOURCE WATER ' <br /> 3. �NEW CONSTRUCTION n REPAIRS <br /> 4. � OTNER�SOeclly� � �t�.L"I�/EU _ I <br /> COMPLETE IF TNIS SAMPLE IS A CHECK SAMPLE ' I <br /> ��F�,�„s,a�ti� fv'UV 1 �� 1988 � I <br /> PREVIOUS SAMPLE COLL[CTION DATE � <br /> REMARNS�. � I <br /> LABORATORY RESULTS 1Fon ua use oNw� ' . <br /> 1�1PI��COLIFORM STD PLATE COUHi SAMPLE NOT TESTEO ', <br /> BECAUSE: <br /> ��,�5���..�.,.���.. /�»i . <br /> MPN DILUTION TEST UNSUITABLE � Semple iao Old � . <br /> ���'"' 1. � Conlluen�Growih ❑ Nol In ProDer Coninlner <br /> MF COLIFORM <br /> 2. � TNTC � Insulllc�ent Inbrmntlon <br /> ���� , Provl4eA—Ploeee ReaU <br /> � Inelmcllons on Form � <br /> FECAL COLIFORM 3. ❑ Evcass Oe6rls <br /> ❑ MPN ❑ MF 4 � � � <br /> �On nn <br /> FOR D INKINO WATER SAMPLES ONLY.THESE RESULTS ARE' � <br /> �SATISFACTOfiV ❑ UNSATISFACTORY , <br /> F[REVERSF 90F OF Gft[EN COPY FOR EXPI_4NATION OF RFSUlTS <br /> L�B NO D�iE.TIME RECEIVEO- NECEIVEO BY <br /> �i ii� .� ��7� �" <br /> �' ' f.� <br /> p�iE REPORTEO ��BOP�TORY. <br /> /; ��� �� <br /> RFM�iiNS <br /> v <br /> �/ , ' <br /> wnTrR surri ien coPv " , <br />