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AyH <br />H 14 <br />u•,,r•, r� .,,,,� <br />t" <br />t <br />STATE OF WASHINGTON <br />DEPARTMENT OF SOCIAL AND HEALTH SERVICES <br />y <br />WATER BACTERIOLOGICAL ANALYSIS <br />0 0 <br />FC � r'D <br />SAMPIt LULLFCTIUN. RCAD lNS1HUCilUNS ON BACK OF 60IUEN1100 CUI'Y <br />N FH <br />If Instructions are not followed, Sample will be re!ected. <br />sJp s <br />DATE COLLECTED TII�ECOLLECTED COUNTYNAME <br />H <br />MONTH DAY YEAR <br />TYPE OF SYSTEM1 IF PUBLIC SYSTEM, COMPLETE' <br />❑ PUBLIC L'RCII LI ASS <br />I.D. No. <br />a y <br />1' p 7 A <br />❑ INDIVIDUnL <br />N CA y <br />N <br />NAME. OF SYSTEM <br />l <br />O 1.7 (A <br />SPICIIICIOCATIDNWHt RESAMPi[COI(f Ctf SYSRMEAYMAtMEANAMIRIOTRIRONEW <br />SAMPLE COLLECTED BY: INS.) <br />SOURCETYPE <br />❑ SURFACE ❑ WELL ❑ SPRING ❑ PURCHASED ❑ COMBINATION <br />or OTHER <br />SEND REPORT 70: (Prim Full Nt9°. Addroll and IP Cage) <br />E1 <br />t(r.S ENScL) <br />top T 2° F"1.�r <br />J <br />E 1 WASHIHDTON <br />TYPE OF SAMPLE <br />rc.rr. —.1 rn.nrn <br />6 ❑ Flea) <br />1. DRINKINGWATFR Chlorinated(Resldual:_Tolal_ <br />�� <br />check treatment --jt ❑ Filtered <br />❑ Untreated011her <br />lI''or <br />2.0 RAW SOURCE WATER - <br />j <br />3. 0 NEW ONSTR CT ON or E�II SL�I @Ls 0 l� <br />� <br />4. ❑ OTHER ESWNY1 <br />!l <br />COMPLETE IF THIS SAMPLE IS A C I K SPaeFEn 6 1g88 <br />�j j( �J <br />PRLVIUU51 AB NO <br />PREVIOUS SAMPLE COLLECTION DATE <br />ease, a' <br />REMARKS: CITY OF l_`/Lltcf <br />Public'YlVfa7 <br />LABORATORY RESULTS (FOR LAB USE ONLY) <br />ease, 1sr_' MPN - COLIFORM <br />� _ /5 me.. Rwm,. <br />MPN DILUTION <br />STD PLATE COUNT <br />41 <br />SAMPLE NOT TESTED <br />BECAUSE. <br />4 Sample Too Old <br />TEST UNSUITABLE <br />/100 M <br />1. ❑ Confluent Growth <br />❑ Not In Proper Container <br />view ease, <br />=1 I MF CS%I:IfORM <br />2. ❑ TNTC <br />Insulllclanl <br />J <br />�.. �nD m <br />Information <br />Provided —Please Read <br />� <br />3. ❑ Ereess Debrle <br />Instructions on Form <br />FECAL COLIFORM <br />❑ MPN ❑ MF <br />4 ❑ <br />El <br />(Leffirl/De ml <br />WATER SAMPLES ONLY. THESE <br />RESULTS ARE: <br />FOR{[. <br />LaDD�RINKING <br />'SATISFACTORY <br />❑ UNSATISFACTORY <br />SEE REVERSE SIDE OF GREEN COPY FOR EXPLANATICN OF RESULTS <br />LAB NO. DATE.TIMER[CEwED- RECEIVED BY <br />aif <br />DAIL. REPOHtEII LABORAIORY <br />REMMKB <br />WATER SUPPLIER COPY Ar <br />