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(` �T�rE or w��oroM ; <br /> oa�trurr os Nu►ni <br /> WATER BACTERIOLOOICAL ANALYSIS <br /> SAMPLE COLIECT10N: FEAD INSTHUCTIONS ON OACK OF GOLDENflOD COVY <br /> 11 Instrucllons�ro not followe0,aampla will be rs�ected. <br /> DATE COLLECTED TIMECOLLECTED COUNiY NAME <br /> MOMTN OAT YFAR 1 /] � �� / <br /> 1��M ❑ PM���tJhOI41S� <br /> iYPE OF SYBTEM F PUBLIC BYBTEM,COMPLETE: <br /> h�puei.ic I.D. No. ciRCIELVSS <br /> ❑ INDIVIDUAL � 2 3 0 <br /> iwn..wr��errr.� <br /> NAME OF SYBTEM <br /> ' ��/.Q ''` O- P <br /> UQ �e, � <br /> SPEpFICIOCAT10N) MENES�MRELOLI CiE05Y51FMpMEA/Mlil W�MENA1HfR10NE/A <br /> �y��kM W�r�eM.�n�u�m.�aunwtl <br /> �'KP i-� L•�`� '` �. (�Z � <br /> F�OIi n� AJ... C�b/ '1 •T�Q/D <br /> BAMPL LLECTEO BY:Mwirl �' / _/ <br /> Q r r D l� � / d l(��� e k Ufa� i <br /> 60URCETVPE <br /> ❑ 6UHFACE ❑WELL ❑ BPRINO y�PURCMABED ❑ �MBINATION <br /> a OTHER <br /> SEND qE RT TO:rvp�1 Full NMM,MO�M�2ip�1 �/, <br /> �: �.i n'f- E✓ P,,. � «� C �/)o..�J <br /> a � C oXa� <br /> ✓ e � � "� WABNINOTON �°/ <br /> TYPE OF B�MPLE <br /> F��a+r on u�W caiwirY <br /> 1. � DHINKINGWATER � ChlorinatMl��lOw1:_To41_fraa) <br /> check Iro�lmant—► ❑ FIIIersE <br /> ❑ Unlra�lsO or OIMr <br /> 2. MW SOURCE WATER <br /> 3. NEW CONSTRUCTION a REPAIRS <br /> 4. O1HEH�6pxlly) <br /> COMPLEiE IF THIS SAMPLE IB A CIIECK SAMPLE O S S� <br /> PIIEVIOUS IaB N0. <br /> PRE.IOUS BAMPLE COLLECTION DATE <br /> REMARKB: . � r.-...,, n ,rir,. <br /> � �> i �iipn�l <br /> LA�OIIAT011�IIE6ULTE Ira�w wc aan <br /> MPN•COLIFORM 6TDPLATE COUNT BAMPLENOTTE6TE0 <br /> BECAU6E: <br /> _�5ue..od��.. �mi <br /> MPN DILU710N TEST UNBUITABIE � �mpla Tao OIU <br /> ��^� 1. � Conlluan�Grow1� � Not In Prop�r Conl�lner <br /> ��CALIFORM 2 � TNTC � IntuI11a11n11nlwm�tlon <br /> �/pp PralA�E—Plaw MW <br /> Inelruatlons on Form <br /> FECAL COLIFOR 3. O Exeas�Dechs <br /> F 4. ❑ ❑ <br /> �oo m <br /> FOR DAMMINIO WATEA BAMPLE6 ONLY,THE6E NESULT6 ARE: <br /> �BATSFACTORY ❑ UNBATISFACTORY <br /> ^SEE HEVERSE SIDE OF 6REEN COPV FOR E%PLANATION OF RESULTS <br /> UB NO. 011TE.T�11E PEGEIVED— RECEIVEO BY <br /> DA � <br /> � TE PE T RY: . ' <br /> DON I�06a021�.1Lq � '�� <br /> OP CENTER COPY e� <br />