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<br /> Har.e1 W..Myt.a D.pon m.�t d SeJ.I and..9 1 .9
<br /> Naebh S«dr....Wathn a 17•I
<br /> dp.rtm.nr ilfU S.d.l and 1,a 1 S)rdr« Smith Isw.r,S.mtl.,W..hinym 9eI0e
<br /> NaebF San1m DlYhbn a 11 e
<br /> lmltF lows U.'".wa, r 1104 WATER BACTERIOLOGICAL ANALYSIS
<br /> WATER BAC�E IOL6JJJJJGA ANALYSIS READ INSTRUCTIONS ON BACK OF GOLDENROD COPY ,
<br /> READ INSTRUCTIONS N BASK OF OIDN ROD COPY IF INSTRUCTIONS ARE NOT PROPERLY FOLlOWEO,
<br /> IF INSTRUCTIONS RE NdT PROPERLY OLLOWED, SAMPLE WILL BE REJECTED.
<br /> SAMPLE,W ILL BE REJECTED.
<br /> 4�T
<br /> OF L CO.-CITY a,a { r r ..FORIAI USE ONLYCO-CITY xra a' ...r -4 f ;. . . .�� �♦ I UB: O � --~ ��� '111 `•3P ( �YA ` S7. 1TED mem DATE STARTEDunFi \: a m+ neDer raa DATE COLLECTED ,n+o, OATESTARTED fi bFri I.+N uu .NO.I►ubhe SFn•md COUNTY NAME
<br /> AM 1 1111 un un nn un
<br /> TIME OF DAY xau I. .NO.fPublic System.') C•UNTY NAME _- L�j PM 7 )FI _
<br /> COLLECTED 0^,y,1 uu un ,.n uu us. _ [
<br /> ❑PM 7 �'i•IlJ/T�/l/\ �:�•`-� N Mf OF WATIR FT-STEM CIRCl7 Q a!
<br /> NAo►7Ntff T7- ORCLECLA55 r 1r5
<br /> - 1 J . srsrunAotRl3
<br /> (�yr' f
<br /> F ���'O i7 1'WHI'h R r SAMM WAS
<br /> 16TW ADDHSf � MRf WA! LLECTED IBn t aNaa,r,drr.N,!x o.,rtrcl
<br /> Q4NW n z A_� Oui FM.
<br /> LOCATION WNIR SAMR!WA3 C011fC110doNen,s,MN.!IF N.,en.l
<br /> SoEi�, �n ^` COLLECT10 BYA CN D
<br /> y
<br /> COLLfCIFD BY:Lra,wd .. .. ,•,
<br /> TYPE OF nN unldpal IndnMal PrlYne
<br /> TYPE OFeiaes 1 r+MudHpol IndusMol Mvata-.-'- SYSTEM r E. Community w 7 Q Commercial ar 7 Raldm<e
<br /> SYS11M'.' Conon snly on 7 O Comm«sial °r 7 0 RQs1zc* I SEND REPORT TO:IPnnI Full Nome,Address and Zip Codel 4r
<br /> SEND REPORT TO!(Paint Full Nome,Address and Zip Code! - any�(•,�� ICL Jr ob{-
<br /> i�1Li��l ljLnllrrTi _ -r��t� CEQr1iZ /-� YLZ �1�- ' r _�
<br /> '2):�),pp Car11Ap n fCi:��i 2,..t 1 EP7 l Ir ?r WASHINGTON
<br /> WASHINGTON ' SOURCE TYPE :vi
<br /> SOURCETYPE :nr Combmuon 10 Surface; 70well• 305pup. e((yPurd.osed, 1190 orOther
<br /> 10 Swlperr 70 w.I1; SO SM-19. AG1.P'errtae; 90 ix0rw "t TYPE O�F�SAMPLE •a•' ICHFCK ONE CONI^YI N SmmNng Sw,mmin{
<br /> Ir �a « 7O Rnw 7s .'rho'. A0►pal SO Beach
<br /> TYPE OF MPIE 'aa' 1CNECA ONE ONLY( Naw Sw,mm,,.q Sw,mm.ng ���igrq " . 111 «
<br /> 1 r 'pylar« 7O Bo« 7�A�d O Pool
<br /> so &11th n�'."Y sMDlnh pNssr L� MCPJ.
<br /> Son,rory Shellhth � O,1y. _ DO Sur... 70 5twww" BO crud, 9 sp.pM
<br /> 00 sauce 70 Seowar« BO Srudy 94y TpR,ly1 r/V��f/i • REVIOUSMNON NON-CONFOW-UPORMING SAMPLE? I O Yn 0 0 No
<br /> IS THIS SAMPLE A FOLLOW UP TO A no IF YES,GIVE PREVIOUS LAB.O
<br /> PREVIOUS.NONCONFORMING SAMPLE? T O Yn 0 O No
<br /> IF YES,GIVE PREVIOUS LAB.NO _ ,ea SYSTEM TREAATa-TsM``E��NJ 40eck only Fix Dnnking Was«Sampled
<br /> .ea SYSTEM TREATMENT iChNk only for Drinking Wolff So-00 10 None; 7.�isa,Iainal,en; J 0 Filrranom d O Fhxnddhor..
<br /> i
<br /> I Q No,r. 1 O-chi«,rgnon; 7 0 Filmosion; e 0 Fluoridonpn. 9001h«ISpR,fyl
<br /> 9 0 Orh«ISp«uYl REMARKS,
<br /> REMARKS,
<br /> LABORATORY RESULTS
<br /> LABORATORY RESULTS SEE REVERSE SIDE OF PINK COPY FOR INTERPRETATIONS
<br /> SEE REVERSE SIDE OF PINK COPY FOR INTERPRETATIONS A.COLIFORMS PER I00.d C.FECAL COLIFORM, ❑ RESUBMIT SAMPLE
<br /> A.COLIFORMS PER 100fel G FECAL COLIFORM ❑ RESUBMIT SAMPLE S TUBE MPN TEST Ieol / Wml Test Umumble
<br /> RN because-
<br /> 5 TUBE MTEST iWI Tn,UmunabN 8«amt I.❑. 0/S-r7.7 MPN no 1.❑Conlluenl Uowrh
<br /> N _ /I OOmI x7.ea_• E- 2.01141C
<br /> L❑-� O/S�c1.7 MPnal.❑ ImCmowrh 2.[]- 1/5-2.2
<br /> 120,110,120,110,_ 2.0•-E- 7. ,NTC MF /IOOmI 7.❑Earass DeWn
<br /> 2,[3- 1/3.7.7 S.❑�• 7/Sx S.1
<br /> w /I DOW ].❑Ernst DeMn xraal E- e ❑
<br /> 3,[3- 7/3-S.17/S•97.[3- .
<br /> xraNs_•_E _ e ❑ e ❑RESUBMIT SAMPLE ns-YN
<br /> e.❑+ 3/5•9.7 ❑RESUBMIT SAMPLE 11,.11, Si[3- e/5• Id Sample Reieaed Beeause,lCheA 0.01 Morrell
<br /> So- 415-16 Sample Relwed Became:ICh«k 0,.e O,Morel 60- Sig-aid 1• ❑Sample Toa Old
<br /> e.0- Sig-.IA 1. O Sample Too OldIAF n /I OOmI 7. 1-]Fee Not Provided
<br /> MF n /IOOmI 7. ❑Fee Not Provided atwl ye E L 3. ❑Sample Recwved Toa late In Week
<br /> 3. ❑Somple Received Too late In Week MPN DILN.TESTS 4. [jImullrrnnt Inlormauon Provided.
<br /> MRI OIW.TESTS d. ❑Insulfiaent Inlormplion Provided. /100 ml Please Read Instructions On Form.
<br /> /100 ml Please Read Instructions On Form. NsaN_•_E_ S. ❑Not In Proper Container
<br /> w+r_e_E_ S. ❑Nor In Proper ContainerB.STD.PLATE COUNT 6. ❑looked Out
<br /> S.SFO.PLATE COUNT 6. ❑Leaked Out7• ❑other Ispecityl
<br /> 7• ❑Other ISpedfyl .;.• .. /ml
<br /> /ml r as•ea_•_E_
<br /> nava_•_E_ REMARKS:
<br /> REMARKS: -t
<br /> . RATE
<br /> ECEIVEDM COMPLETED'] /
<br /> RECEIVEDME7.::;•�coMPLEtto WATER SUPPLIER COPY
<br /> WATER SUPPLIER/9fOYT ' `Q '
<br /> i
<br /> L _ ._ - _..-. . .. ._.._.... -. .. '
<br />
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