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. _-_ '^:�'-' mm a.vfp b•q Load WmFlnp,n '
<br /> Lal•a1 W-,hlnp-n Dap•rtm•nt$.S•<lel and N. 1 Lnlo,
<br /> a,P.rf m,nr S.Ld•1 end Noah S•.•I<o T.v .$•nju,'W.An R.."9 /\
<br /> NvdtF Sanlm grnlan R V ♦ SmbF bw«,b•ula,Wv.hlnpm 031 at
<br /> c Smith Tal" s.v,tla,Wn11' tj .19. WATER BACTERIOLOGICAL ANALYSIS
<br /> WATER BAC�E IOLd/G ANALYSIS READ INSTRUCTIONS ON BACK OF GOLDENROD COPY. ,
<br /> READ IN STRUCT�NS NBA CK OF OLDtNROD COPY IF INSTRUCTIONS ARE NOT PROPERLY FOLLOWED,
<br /> IF INSTRUCT NS RE NOT PROPEKY OLLOWED, SAMPLE WILL BE REJECTED.
<br /> SAMPLE WILL BE REJECTED _ FOR U1/�SE DI Y• CO.-CITY •ra I,
<br /> FOR LAB USE ONLY CO CITY Ira u, w LAB.NO " /
<br /> DATECOLLECT60 .,s2oi DATE STARTED un u,as
<br /> DATECOLLECTED Ivo, DATE STARTED un as a.(s Munm our vas.
<br /> 6wrer �o.ar y„q�. ; .,[ .•^'. �i`,t':Lc`i�IY �u - � u.,-m
<br /> TIMEOFDAY « .D NO IPublic�S-.:y�atem—,fUy( VCOUNTY NAME
<br /> TIME
<br /> E
<br /> TIME OF DAY I. ,mIwhblicSpm
<br /> ht�a5i1' k' -
<br /> '
<br /> 1COUNTYAAMIE COILECTEGAMI uu un um ua un
<br /> COLLECTED 0'AM I urr u« uv nar I RPM 7
<br /> []PM 7 > k)1-k1-<M l � XAM!Of N ATEt SYST[M
<br /> MAMA OLM r,,)�SS y CIRCLE CIA!
<br /> CIACIE Cl A55 _L(,_!-L_
<br /> e-0 / 1 7 3 4 SYSTEM ADDRESS
<br /> STSIIWT��AODRtlS r 'p L( i�' \II('I! ,
<br /> 1[41161'l � �,'--`wS p cAJ L 10 WMfKSAMPLE WAS LL[CTEOIba,eMan,alw.Sir a.,act
<br /> LOCCATI,O�N W,XIK SAMPLE WAS COLLECTED Ills, an,•dwN,SIF a.,wa.l j lI)" F7 �N
<br /> 7<../a/-7 r,, A.)n wt f, COLLECTED BY:(1y[�� ) '
<br /> COLIECTIO BY:IWmd K�'�ly
<br /> r'• f A I�'.�!• <? 'AS TYPE OF u« c'ALunidpol Indurol Private
<br /> TYPE CF'ue, I (Dfllunkipol Indualdal Privale . SYSTEM r I CeMmunily or] O M
<br /> Commeedal Oe 30 Raaldenae
<br /> SYSTEM Community pe2 0 Comtrlwdal °e S Refidence SEND REPORT TO IPnnl Full Name,Address and Z,p Codel a
<br /> SEND REPORT TO IPunt Full Name,Addrns and Zrp Codel
<br /> L1 Z71-6V I X111) u '\,I !
<br /> �)C7 CEC)r��
<br /> �� 7c7 �'<ti4P FFJG2 nFl�i
<br /> WASHINGTON ^a1 1 1
<br /> WASHINGTON •-�'l SOURCE 1YPE mI � / Combnouon
<br /> SOURCE TYPE :an Comb na,On 10 Sw10u, 7O Well, OO S,,ng, 4LVeP,.mla,ed: •.9O aO,hv
<br /> 10 Swfoc . 2 W.A. 7O Spring, 4l21-Pdr<no,ed, 9O o,Omer , TYPEO_F MPLE 11-1 ICNECKONEONLY,
<br /> TYPEOF MPLE ICHECKONEONLYI Rnw Ne✓ 'PoolS�I .q Swrmmm5
<br /> uu Naw Swrl 5wimm�nq Ic ' nn Vn9�W t�« 7O War« 701Ge� 4O Pool SO Bco<h
<br /> 1 gY7nt« 7O War« 0�MT�4O Pool 50 Bea<h Sonuory Shellinh
<br /> Somrory Snellinh ,� Oryry.r 6O SwveY 70 Seawom eO S,udv 9 V1ipttrhl + '•1'��,
<br /> 60 $mreY 70 Smwo,« BO Ludy 91�e<,Ip E/1 l ^g l/ IS THIS SAMPLE A FOLLOW UP TOA u«
<br /> 15 THIS SAMPLE A FOLLOW UP TO A u« PREVIOUS.NONCONFORMING SAMPLES I O Yes O O No
<br /> PREVIOUS.NONCONFORMING SAMPLE? 1 O Ye, 0 O No IF YES.GIVE PREVIOUS LAB NO
<br /> IF YES,GIVE PREVIOUS LAB NO. _ as SYSTEM TREATMENT aChe<L only lo.0rmbng W,«50mpl•,I
<br /> .•« SYSTEM TREATMENT ICh«k only for Drinking Wow Sompinl 10 None 1 0 61onnohon: 7 O 611,01,.¢ 4 O Fluond000n,
<br /> !�
<br /> �.i
<br /> 10 Nor,.; dC'
<br /> T hloru,000n: O O filrmenn, 4 O fluoudauoo 90Otntt lSp«.Ip
<br /> 9 O Oth«ls,nmlr, REMARKS:
<br /> REMARKS,
<br /> LABORAIORY RESULTS
<br /> LABORATORY RESULTS SEE REVERSE SIDE OF PINK COPY FOR INTERPRETATIONS
<br /> SEE REVERSE SIDE OF PINK COPY FOR INTERPRETATIONS _ A.COLIFORMS PER I OOml C.FECAL COLIFORM ❑ RESUBMIT SAMPLE
<br /> A.COLIFORMS PER IOOmi C.FECAL COLIFORM ❑ RESUBMIT SAMPLE 5 TUBE VPN TEST .., Tnt Unwnable Bttame
<br /> 5 TUBE MPN LEST ua, /loom! Tm Ummrnble BttumO 10— 0/5�•71 MPN I OOmI noel ❑Conlluem Grox+h
<br /> 1❑0' 0/5-<77 MPN no,I ❑Conllvem Growth 7.❑+ I/5-77 ....•a_• — E_ 2.0114TC
<br /> m•a_- —E_ ].❑INTC MF /100m1
<br /> 7.0+ V5-7.7 3.06rn,Debm
<br /> MF /loom! J 01.cn,Deb,., J ❑— E/5-51
<br /> E _ 40 40— 3/S-92
<br /> 4 0— J/5 w 9] ❑
<br /> 5❑—� 4/5- 16 RESUBMIT SAMPLE mna
<br /> so— u5- 16 C1 RESUBMIT SAMPLE man Sample Relnted Because.lChM One Or Morel
<br /> Sample Rejected Berau,e.ICh.h One Or More, 60— 5/5- .16 1, ❑Sample Too Old
<br /> e.❑+ 3/!- .I6 1. ❑Sample Too Old
<br /> MF /IOOmI Z. ❑fee Not Provided
<br /> MF /I OOmI 2 ❑fee Not Pro«ded .' E 7 ❑Sample Received Too Late In Week
<br /> E . L J, ❑Sample Received Too Late In Week MPN DILN TESTS 4. ❑Imulhaenl Infoemahon Prov,ded.
<br /> MPN OILN TESTS 4 ❑Imufbaent Inlo,mohon Provided. /100 ml Please Read Instmeiom On Form.
<br /> /100 ml Please Read In,,wmanf On Form. „a,«_•_E_ 5 ❑Not In Proper Container
<br /> 5. ❑Not In Proper Conlo,ne, B.SIO.PLATE COUNT 6. ❑leaked Out
<br /> B.STD.PLATE COUNT 6. ❑Leaked Oul, 7. ❑Other ISphifyl
<br /> 7. ❑Other ISpecifyl /ml
<br /> /ml
<br /> REMARKS. a
<br /> REMARKS:
<br /> _ DATE B TIMEDATE
<br /> DATE&TIME_ RECEIVED
<br /> RECEIVED ). '. =/ �� DATE --. 5 MPLETED') ) __
<br /> MP TED'
<br /> WATER SUPPLIETCOP// WATER SUPPLIER COPY
<br /> L
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