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HomeMy WebLinkAboutWTR2701812PROJECT NAME: FAM �J v o4 %7d2Z ALIAS: oC J� d o6e�SP2 6/ CONTRACTOR (IF KNOWN): PROJECT NUMBER: ZV 4- � 7 WORK ORDER NUMBER: ? 7S-3 STATE CONST. REPORT SIGNED BY: /Z-11- 17 YEAR PROJECT TAKEN INTO PLANT: RECORDED BILL OF SALE: �� d f l a 3/ 7:2 RECORDED EASEMENT: f D22Z Ol> zo 4- lope COST DATA INVENTORY: PIPE $ HYDRANT $ BACKFLOW TESTS: Y N v PURITY TEST: no. taken S PRESSURE TEST: 1- l 1-11 7 Test No(s) Document l\ u>iP-Z-71VIZ CONSTRUCTION REPORT FOR PUBLIC WATER SYSTEM PROJECTS Effective September 9, 1983 the following Regulation applies: WAC 246-290-040(3) - A construction report shall be submitted to and accepted by the department within sixty days of completion and prior to use of any project for which plans and specifications have been approved by the department for projects designed by a professional engineer. The construction report must be signed by a professional engineer. The report shall state in the opinion of the signee whether the project has been constructed in accordance with approved plans and specifications and the installation, testing and disinfection of the system were carried out in accordance with department regulations. a) If a project is being completed in staged construction, attach a map and description of portion of project being certified as completed as approved on date given below. b) As future portions of staged construction projects are completed, each must be certified as required by WAC 246-290-040(3). c) Additional certification forms are available upon request from DOH offices listed below. City of Renton DOH Water System No. 71850L 200 Mill Avenue South Renton, WA 98055 Referendum No. (if any) PROJECT NAME AND DESCRIPTIVE TITLE: Date Specifications Approved City of Renton Water System by Department of Health King County August 18, 1993 Renton Project Number (J., T P -7 1 � 11 (1990 Comprehensive Water System Plan) Project Title: A"Ywtwe"It; ( Be.45c:.( P�u�.t %�✓. 5 --jT. The undersigned engineer or his authorized agent has inspected the above -described project, which as to layout, size and type of pipe, valves and materials, reservoir and other designed physical facilities has been constructed in accordance with specifications approved by the Secretary, Department of Health, and in the opinion of the engineer, the installation, testing and disinfection of the system was carried out in accordance with the specifications approved by the. c e�ary. Engineer's Seal ,!' j� Cl Please return completed form to DOH office checked below: NW Drinking Water 0 Environmental Health 1511 Third, Suite 719 Seattle, WA 98101 SW Drinking Water ❑ Environmental Health Mail Stop 7823 Olympia, WA 98504 Engineer Qee_ I7 7. Date Eastern Drinking Water ❑ Environmental Health 1500 W Fourth, Suite 305 Spokane, WA 99204 H: D [ V [ S l ONS\UTI LITI ESOOCS\96-367. D0C CITY OF RENTON PUNNING, BUILDINGI?UBLC WORKS DE_-D.-�RT`�fENT FINAL COST DATA AND INVENTORY NAME OF PROJECT wTR- City Lights L.L.0 SWP- TRO- 7Er- 04. the request of the City of Renton, the following information is famished concerning final costs for urrnprove,:It:.Ls nstailed and turned over to the City for the above referenced project. • •III •. •ti L.ngth Size Type WAT.=R-MAIN A n -T L. F. of ) TV . wAr�. Airy L. o f saw_ n-T o WATE.RMA]N L... of WATFRMAIN L.:. of __ 2 6AC Hof —I�- ' 2 GATE VALVES EACH of 8 " GATE VALVES EACH of GATE VALVES 92 855.00 • 5 EACH of FEE YDRAigT ASSENffiLs.S S 'Cos(of Fire :?ydrants must be listed separately) S 63 190.00 S . 0 ;;nc;ude E^ginecring and Sales Tax if applicable S 045 00 .:RYCF:sly? Sys—., - TOTAL COST FOR WATER S f a I r-f 15 6 n J I nQs'- SYST;M- Size 3 7 of 611 Type PVC SEYE.Z MAIN -- _ Z. Of �— �V C.; SEWER MALN of SEWER MAIN 4 EA of 4 8 ° DMZ =R uANHOLS --T— EA of 5r DIAMETER MANFOLHS ;Incluoing E ngineenrig and Sales Tax 89 9 20 . 00 i applic.c:e; S TOTAL COST FOR SANITARY SEWER SYST" M S PC a 9 n- 00 Size Tvoe STORM of Ea. of :oR.M EA of j�0R1.f (Including zn ginesring and Sales Tax if applicable; TOTAL COST FOR STORM DRAL*IAGE SYS-1,24 3 ET 'MPROVEMENTS: (Including Curb, Gutter. Sidewalk, Asphalt ?avement) S 9 730.56 =.irb. Gutter. Sidewalk: L.F. .asphalt hvemenr. 6050—SY or L.?. of3"ATB 2"CB Width S 30652.50 SIGNALI2ATION: (Including Eng. Design Costs. Cary Permit Pees, WA St Sales Tax) Not applicable. STUET LIGHTING: (Including-Eng. Design Costs, City Permit Fces, WA St Saks tax) . vf ?Cles NIA S �-A ?nnt signatory name o ;ns/COSTOAi?.DCC.'bn day Phone w.6 (SIGNATURE) (Signatory must be authorized agcr.t or owner of subject developm-,n') CITY OF RENTON WATER DEPARTMENT Pressure Test $ Purification Test Form PROJECT NO. 97 �9� NAME OF PROJECT i � 5 ki�l PRESSURE TEST TAKEN BYv Of AT A PRESSURE OF ;ZIl> PSI, FOR ON q — 9 _0 /JV M-illlA TEST ACCEPTED ON 9-8 _Ci 7 ,k-, q PURIFICATION TEST TAKEN BY 0 ra)C j 9N PURIFICATION TEST RESULTS, SAMPLE #1 Fib OK SAMPLE # 2 � � _�IT � r OIL SAMPLE #3 REMARKS: 0,41yil f! ek�n - 1Q--Iv' c , ot-1�- -�11 Laucks Testing Laboratories, Inc. 940 S. Harney Seattle, WA 98108 WATER BACTERIOLOGICAL ANALYSIS SAMPLE COLLECTION: READ INSTRUCTIONS ON BACK OF GOLDENROD COPY If Instructions are not followed, sample will be rejected. DATE COLLECTED I TIME COLLECTED COUNTY NAME MONTH DAY YEAR ❑ AM ❑ PM TYPE OF SYSTEM IF PUBLIC SYSTEM, COMPLETE: ❑ PUBLIC CIRCLE GROUP ❑ INDIVIDUAL I.D. ND. A B (serves ony i residence) NAME OF SYSTEM SPECIFIC LOCATION WHERE SAMPLE COLLECTED I TELEPHONE NO. SAMPLE COLLECTED BY: (Name) DAY ( EVENING ( ) SYSTEM OWNER/MGR.: (Name) SOURCE TYPE ❑ GROUNDWATER UNDER SURFACE INFLUENCE []SURFACE ❑ WELL or [—]SPRING ❑ PURCHASED or []COMBINATION WELL FIELD INTERTIE or OTHER SEND REPORT TO: (Print Full Name, Address and Zip Code) WASHINGTON TYPE OF SAMPLE(check only one in this column) ❑ ROUTINE Chlorinated (Residual: Total Free) DRINKING WATER ❑ — check treatment ❑ Filtered ❑ Untreated or Other ❑ REPEAT SAMPLE Previous coliform presence Lab # Date ❑ RAW SOURCE WATER Source # Fs] m ❑ Total Coliform ❑ NEW CONSTRUCTION or REPAIRS ❑ Fecal Coliform ❑ OTHER (Specify) REMARKS (LAS USE ONLY) DRINKING WATER RESULTS ❑ UNSATISFACTORY, Colifonns present ❑ SATISFACTORY, REPEAL U E. Cdi present ❑ E. Coli absent -nt SAMPLES REQUIRED ❑ Fecal present ❑ Fecal absent OTHER LABORATORY RESULTS TOTAL COLIFORM /100 ml E. COLT /100ml FECAL COLIFORM /100 ml PLATE COUNT /ml ANOTHER SAMPLE REQUIRED SAMPLE NOT TESTED BECAUSE: TEST UNSUITABLE BECAUSE: ❑ Sample too old ❑ Confluent growth ❑ Wrong container ❑ TNTC ❑ Incomplete form ❑ Turbid culture ❑ ❑ Excess debris SEE REVERSE SIDE OF GREEN COPY FOR EXPLANATION OF RESULTS LAB NO. (7 DIGITS) DATE, TIME RECEIVED RECEIVED BY DATE REPORTED LABORATORY: REMARKS DOH 306-002 (REV. 4/92) WATER SUPPLIER COPY INTERPRETATION OF RESULTS FOR DRINKING WATER The analysis performed on this drinking water sample is an examina- tion for the presence of coliform organisn s in the wa.c! and '--dicates the bacteriological quality of the sample. The prasence of coliforr. organisms is used by health organizations worldw;de as an ind,,ator for the possible presence of other disease ca,:sing organ sms. REPORTING OF RESULTS, Group A Pubhc Water Systems must repon,, the re ults of Du-,h:ng Water Analysis to the State as specifieJ in WAS 246-29C 180. SATISFACTORY RESULTS - The absence of coliforms from ary sample .s satisfactury P _, er system maintenance and bacteriologica. monitoring shout l' , e con- tinued routinely to insure the safety ct the water suppi� UNSATISFACTORY RESULTS: Any coliform presence is unsatisfactory. The presence of coliforms indicates the system is r'ot pr:perly protected against contamination and may be unsafe for h. nan con- sumption . Unsatisfactory samples should be rnvesti g.4ted IMMEDI- ATELY and repeat samples submitted Contact your ;ocat health department or DOH Regional Office for assistance in de*;rminirg the source of contamination and corrective procedures. When fecal coliforms or E.coli are reported present in a sample, the IMMEDIATE ACTION REQUIRED by a Public System is. 1. Investigate to determine the cause and correct the situation. Your local health department or DOH Regional Office can assist you. 2. Submit repeat samples as specified'n WAC 24-290-480. 3. Publicly notify the users of public water systems as speci- fied in WAC 246-290-480. 4. Contact your local health department or DOH Regiona! Office as specified in WAC 246-290-480. TEST UNSUITABLE: Resample Immediately "Confluent Growth" means bacteria have grown into a continuous mass which makes counting impossible. "TNTC" means b�icteria are too numerous to count. "Excess Debris" means that particulates in the water interfere with the interpretation of test results. ''Turbid Culture" means an overgrowth of other bacteria can interfere with celiform anah�siv., if ?nv Inx i-. i;,. 'ir.n , , t.n '- test is chr,{, a j a jesSildO O' OMOim b3Cteiiid Covtzt notT�� o=3cer�[rtneo u tv a Tic sample must be obtained for testing. RESAMPLE: Sample too old. (Sample to be tested must be received within 30 hours). Not in proper container. (Bottle to be used for testing must be purchased from a certified lab within 6 months.) Insufficient volume. (Sample must be at least 100 ml) If not tested, a new sample must be submitted for analysis. FOR ADDITIONAL INFORMATION: Contact your local health department OR the laboratory where this sample was tested OR the Department of Health, Drinking Water Program Regional Office. Laucks Testing Laboratories, Inc. 940 S. Harney Seattle. WA 98108 WATER BACTERIOLOGICAL ANALYSIS SAMPLE COLLECTION: READ INSTRUCTIONS ON BACK OF GOLDENROD COPY If Instructions are not followed, sample will be rejected. DATE COLLECTED TIME COLLECTED COUNTY NAME MONTH DAY YEAR ❑ AM ❑ PM r. TYPE OF SYSTEM IF PUBLIC SYSTEM, COMPLETE: ❑ PUBLIC CIRCLE GROUP ❑ INDIVIDUAL I.D. No. A B (serves only 1 residence) NAME OF SYSTEM SPECIFIC LOCATION WHERE SAMPLE COLLECTED TELEPHONE NO. DAY( ) SAMPLE COLLECTED BY: (Name) EVENING ( ) SYSTEM OWNER/MGR.: (Name) SOURCE TYPE ❑ GROUND WATER UNDER SURFACE INFLUENCE ❑ SURFACE ❑ WELL or ❑ SPRING ❑ PURCHASED or ❑ COMBINATION WELL FIELD INTERTIE or OTHER SEND,REPORT TO: (Print Full Name, Address and Zip Code) Tf V t' j L. n ?VL�' ;31,,'14JLJ I ..VII —r7t' WASHINGTON TYPE OF SAMPLE (check only one in this column) ❑ ROUTINE Chlorinated (Residual: DRINKING WATER ❑ — check treatment o ❑ Filtered ❑ Untreated or Other ❑ REPEAT SAMPLE Previous coliform presence Lab M Date Total_ Free) ❑ RAW SOURCE WATER Source 8 a m ❑ Total Coliform ❑ NEW CONSTRUCTION or REPAIRS ❑ Fecal Coliform ❑ OTHER (Specify) REMARKS:,'� (LAB USE ONLY) DRINKING WATER RESULTS ❑ UNSATISFACTORY, Coliforms present ❑ SATISFACTORY, Coliforms absent REPEAT ❑ E. Coli present ❑ E. Coli absent SAMPLES REQUIRED resent Fecal absent ❑ Fecal P ❑ OTHER LABORATORY RESULTS TOTAL COLI FORM /100 ml E. COLT /100ml FECAL COLIFORM /100 ml PLATE COUNT /ml ANOTHER SAMPLE REQURED SAMPLE NOT TESTED BECAUSE: TEST UNSUITABLE BECAUSE: ❑ Sample too old ❑ Confluent growth ❑ Wrong container ❑ TNTC ❑ Incomplete form ❑ Turbid culture ❑ ❑ Excess debris SEE REVEHSE SIDE OF 6HEEN COPY FOR EXPLANATION OF RESULTS LAB NO. (7 DIGITS) DATE, TIME RECEIVED RECEIVED BY DATE REPORTED LABORATORY: REMARKS DOH 30&1002 (REV. 4M) WATFR RI IPPI ll=n r r)DV INTERPRETATION OF RESULTS FOR DRINKING WATER The analysis performed on this drinking water sample is an examina- tion for the presence of coliform organise sin the water and 'r•.dicates the bacteriological quality of the sample. The presence of coliform organisms is used by health organizations worldwide as an ind,cator for the possible presence of other disease ca-;sing organisms. REPORTING OF RESULTS. Group A Public Water Systems must repert the results of Drir:ning Water Analysis to, the State as specified in WAC 246-290 �80. SATISFACTORY RESULTS: The absence of coliforms from any sample satisfact.;ry P,_ er system maintenance and bacteriolopica; monitcring shoulri be con- tinued routinely to insure the safety cf the pater suppl;. UNSATISFACTORY RESULTS: Any coliform presence is unsatisfactory The presence of coliforms indicates the system is not prcperiy protected against contamination and may be unsafe for h_man con- sumption . Unsatisfactory samples should be investic;ated IMMEDI- ATELY and repeat samples submitteI Contact your local health department or DOH Regional Office for assistance ,n determining the source of contamination and corrective procedures. When fecal coliforms or E.cofi are reported present in a sample, th IMMEDIATE ACTION REQUIRED by a Public System is. 1. Investigate to determine the cause and correct the situation. Your local health department or DOH Regional Office can assist you. 2. Submit repeat samples as specified in WAC 2' -290-480. 3. Publicly notify the users of public water systems as speci- fied in WAC 246-290-480. 4. Contact your local health department or DOH Regional Office as specified in WAC 246-290-480. TEST UNSUITABLE: Resample Immediately "Confluent Growth" means bacteria have grown into a continuous mass which makes counting impossible. "TNTC" means bacteria are too numerous to count. "Excess Debris" means that particulates in the water interfere with the interpretation of test results. ''Turbid Culture" means an overgrowth of other bacteria can interfere with coliform analysis. If any box indicating an unsuitable test is checked, the presence of coliform bacteria could not be determined and a new sample must be obtained for testing. RESAMPLE: Sample too old. (Sample to be tested must be received within 30 hours). Not in proper container. (Bottle to be used for testing must be purchased from a certified lab within 6 months.) Insufficient volume. (Sample must be at least 100 ml) If not tested, a new sample must be submitted for analysis. FOR ADDITIONAL INFORMATION: Contact your local health department OR the laboratory where this sample was tested OR the Department of Health, Drinking Water Program Regional Office. Laucks Testing Laboratories, Inc. 940 S. Harney Seattle, WA 98108 WATER BACTERIOLOGICAL ANALYSIS SAMPLE COLLECTION: READ INSTRUCTIONS ON BACK OF GOLDENROD COPY ff Instructions are not followed, sample will be rejected. DATE COLLECTED TIME COLLECTED COUNTY NAME MONTH DAY YEAR / / ❑ AM ❑ PM TYPE OF SYSTEM IF PUBLIC SYSTEM, COMPLETE: ❑ PUBLIC CIRCLE GROUP ❑ INDIVIDUAL I.D. NO. A B (serves only 1 residence) NAME OF SYSTEM SPECIFIC LOCATION WHERE SAMPLE COLLECTED TELEPHONE NO. DAY( ) SAMPLE COLLECTED BY: (Name) EVENING ( ) SYSTEM OWNER/MGR.: (Name) SOURCE TYPE U GROUNDWATER UNDER SURFACE INFLUENCE [—]SURFACE ❑ WELL or ❑ SPRING ❑ PURCHASED or ❑ COMBINATION WELL FIELD INTERTIE or OTHER SEND REPORT TO: (Print Full Name, Address and Zip Code) WASHINGTON TYPE OF SAMPLE(Check Only one in this column) ❑ ROUTINE Chlorinated (Residual: DRINKING WATER ❑ check treatment ❑ Filtered ❑ Untreated or Other_ ❑ REPEAT SAMPLE Previous coliform presence Lab # Date Total Free) ❑ RAW SOURCE WATER Source # Is] m ❑ Total Coliform ❑ NEW CONSTRUCTION or REPAIRS ❑ Fecal Coliform ❑ OTHER (Specify) REMARKS: (LAB USE ONLY) DRINKING WATER RESULTS ❑ UNSATISFACTORY, Coliforms present ❑ SATISFACTORY, Coliforms absent REPEAT ❑ E. Coli present ❑ E. Coli absent SAMPLES REQUIRED ❑ Fecal Present Fecal absent ❑ OTHER LABORATORY RESULTS TOTAL COLIFORM /100 ml E. COLT /100ml FECAL COLIFORM /100 ml PLATE COUNT /ml ANOTHER SAMPLE REQURED SAMPLE NOT TESTED BECAUSE: TEST UNSUITABLE BECAUSE: ❑ Sample too old ❑ Confluent growth ❑ Wrong container ❑ TNTC ❑ Incomplete form ❑ Turbid culture ❑ ❑ Excess debris SEE REVERSE SIDE OF GREEN UUPY FUN EXPLANATION OF RESULTS LAB NO. (7 DIGITS) DATE, TIME RECEIVED RECEIVED BY DATE REPORTED LABORATORY: REMARKS DOH 305-002 (REV. "2) aR SUPPLIER COPY INTERPRETATION OF RESULTS FOR DRINKING WATER The analysis performed on this drir•king water sample is an examina- tion for the presence of coliform organisn.; in the wa,cr and .. Jicates the bacteriological quality of the sample. The p;asenc�_� of cohfot organisms is used by health orgurizaticns worldwide as an ind,ator for the possible presence cf other disease ca.-sing organ sms. REPORTING OF RESULTS: Group A Public Water Systems must reDcri the rE: uits of Dr:, n!ng Water Analysis tc, the State as specifie in WAr� 246.291") 480. SATISFACTORY RESULTS: The absence )f coliforms from any sample ., sat!sfact"ry. P ,per system maintenance and bacteriologica- monitoring should be con- tinued routinely to insure the safety cf the water supply UNSATISFACTORY RESULTS: Any coliform presence is unsatisfactory. The presence of coliforms indicates the system is not properly protected against contamination and may be unsafe for ". nan con- sumption . Unsatisfactory samples should be investigated IMMEDI- ATELY and repeat saWl s submitted_ Contact your local health department or DOH Regional Office for assistance in denrminir7 the source of contamination and corrective procedures. When fecal coliforms or E.coli are reported present in a sample, the IMMEDIATE ACTION REQUIRED by a Public System is: 1. Investigate to determine the cause and correct the situation. Your local health department or DOH Regional Office can assist you. 2. Submit repeat samples as specified in WAC 2�1 �.290-480. 3. Publicly notify the users of public water systems as speci- fied in WAC 246-290-480. 4. Contact your local health department or DOH Regional Office as specified in WAC 246-290-480. TEST UNSUITABLE: Resample Immediately "Confluent Growth" means bacteria have grown into a continuous mass which makes counting impossible. "TNTC" means bacteria are too numerous to count. "Excess Debris" means that particulates in the water interfere with the interpretation of test results. ''Turbid Culture" means an overgrowth of other bacteria can interfere with coliform analysis. If any box indicating an unsuitable test is checked, the presence of coliform bacteria could not be determined and a new sample must be obtained for testing. RESAMPLE: Sample too old. (Sample to be tested must be received within 30 hours;. Not in proper container. (Bottle to be used for testing must be purchased from a certified lab within 6 months.) Insufficient volume. (Sample must be at least 100 ml), If not tested, a new sample must be submitted for analysis. FOR ADDITIONAL INFORMATION: Contact your local health department OR the laboratory where this sample was tested OR the Department of Health, Drinking Water Program Regional Office. Laucks Testing Laboratories, Inc. 940 S. Harney Seattle, WA 98108 WATER BACTERIOLOGICAL ANALYSIS SAMPLE COLLECTION: READ INSTRUCTIONS ON BACK OF GOLDENROD COPY if Instructions are not followed, sample will be rejected. DATE COLLECTED I TIME COLLECTED COUNTY NAME MONTH DAV YEAR ❑ AM ❑ PM TYPE OF SYSTEM IF PUBLIC SYSTEM, COMPLETE: ❑ PUBLIC ❑ INDIVIDUAL CIRCLE GROUP I.D. No. A B (serves only 1 residence) I � = NAME OF SYSTEM SPECIFIC LOCATION WHERE SAMPLE COLLECTED TELEPHONE NO. DAY( ) SAMPLE COLLECTED BY: (Name) EVENING ( ) SYSTEM OWNER/MGR.: (Name) SOURCE TYPE L I GROUND WATER UNDER SURFACE INFLUENCE ❑ SURFACE ❑ WELL or ❑ SPRING ❑ PURCHASED or ❑ COMBINATION WELL FIELD INTERTIE or OTHER SEND REPORT TO: (Print Full Name, Address and Zip Code) WASHINGTON TYPE OF SAMPLE(check onty one in this column) ❑ ROUTINE Chlorinated (Residual: DRINKING WATER ❑ check treatment ❑ Fiftered ❑ Untreated or Other_ ❑ REPEAT SAMPLE Previous coliform presence Lab M Date Total Free) ❑ RAW SOURCE WATER Source M Fs I ❑ ❑ Total Coliform ❑ NEW CONSTRUCTION or REPAIRS ❑ Fecal Coliform ❑ OTHER (Specify) REMARKS: (LAB USE ONLY) DRINKING WATER RESULTS ❑ UNSATISFACTORY, Coliforms present ❑ SATISFACTORY, Coliforms absent REPEAT ❑ E. Coli present ❑ E. Coli absent SAMPLES Fecal resent Fecal absent REQUIRED ❑ P ❑ OTHER LABORATORY RESULTS TOTAL COLIFORM /100 ml E. COLT /100ml FECAL COLI FORM /100 ml PLATE COUNT /ml ANOTHER SAMPLE REQURED SAMPLE NOT TESTED BECAUSE: TEST UNSUITABLE BECAUSE: ❑ Sample too old ❑ Confluent growth ❑ Wrong container ❑ TNTC ❑ Incomplete form ❑ Turbid culture ❑ ❑ Excess debris SEE HEVEHSE SIDE OF GREEN COPY FOR EXPLANATION OF RESULTS LAB NO. Q DIGITS) DATE, TIME RECEIVED RECEIVED BY 6g/`-")l//f DATE REPORTED LABORATORY: J ` REMARKS DOH 906-002 (REV. 4M) WATER SUPPLIER COPY INTERPRETATION OF RESULTS FOR DRINKING WATER The analysis performed on tros drinking water sample is an examina- tion for the presence of coliform orgamsrra ,n the ware. and-dicates the bacteriological quality of the sample. The p:esenc:e of coVorn-i organisms is used by health organizations vyorldw;de as an irnl,cator for the possible presence of other disease ca:.sing organ.sms. REPORTING OF RESULTS; Group A Public Water Systems must report the re: tilts of Dr!�:King Water Analysis t-- the State as specified in WA(7 246-29_; -:80. SATISFACTORY RE T.S1 The absence of coliforms from any sample .s sat sfactory P-_,;er system maintenance and bacteriologicaj monitoring should be con- tinued routinely to insure the safety cf the water supply. UNSATISFACTORY RESULTS: Any coliform presence is unsatisfactory. The presence of coliforms indicates the system is not properly protected against contamination and may be unsafe for 1•�., nan con- sumption . Unsatisfactory samples should be investi;ate IMMEDI- ATELY and neat samples submitted. Contact your local health department or DOH Regional Office for assistance in de:erminir g the source of contamination and corrective procedures. When fecal coliforms or E.coli are reported present in a sample, the IMMEDIATE ACTION REQUIRED by a Public System is: 1. Investigate to determine the cause and correct the situation. Your local health department or DOH Regional Office can assist you. 2. Submit repeat samples as specified in WAC 24F-290-480. 3. Publicly notify the users of public water systems as speci- fied in WAC 246-290-480. 4. Contact your local health department or DOH Regional Office as specified in WAC 246-290-480, TEST UNSUITABLE: Resample Immediately "Confluent Growth" means bacteria have grown into a continuous mass which makes counting impossible. ''TNTC" means bacteria are too numerous to count. "Excess Debris" means that particulates in the water interfere with the interpretation of test results. 'Turbid Culture" means an overgrowth of other bacteria can interfere with coliform analysis. If any box indicating an unsuitable test is checked, the presence of coliform bacteria could not be determined and a new sample must be obtained for testing. RESAMPLE: Sample too old. (Sample to be tested must be received within 30 hours). Not in proper container. (Bottle to be used for testing must be purchased from a certified lab within 6 months.) Insufficient volume. (Sample must be at least 100 rnl) If not tested, a new sample must be submitted for analysis. FOR ADDITIONAL INFORMATION: Contact your local health department OR the laboratory where this sample was tested OR the Department of Health, Drinking Water Program Regional Office. Laucks Testing Laboratories, Inc. 940 S. Harney Seattle, WA 98108 WATER BACTERIOLOGICAL ANALYSIS SAMPLE COLLECTION: READ INSTRUCTIONS ON BACK OF GOLDENROD COPY If Instructions are not followed, sample will be rejected. DATE COLLECTED I TIME COLLECTED I COUNTY NAME MONTH DAY YEAR ❑ AM ❑ PM TYPE OF SYSTEM IF PUBLIC SYSTEM, COMPLETE: ❑ PUBLIC CIRCLE GROUP ❑ INDIVIDUAL A B (serves only 1 residence) NAME OF SYSTEM SPECIFIC LOCATION WHERE SAMPLE COLLECTED TELEPHONE NO. DAY( ) SAMPLE COLLECTED BY: (Name) EVENING ( ) SYSTEM OWNER/MGR.: (Name) SOURCE TYPE ❑ GROUNDWATER UNDER SURFACE INFLUENCE [—]SURFACE ❑ WELL or ❑ SPRING ❑ PURCHASED or []COMBINATION WELL FIELD INTERTIE or OTHER SEND REPORT TO: (Print Full Name, Address and Zip Code) WASHINGTON TYPE OF SAMPLE(chOck only one in this column) ❑ ROUTINE Chlorinated (Residual: DRINKING WATER ❑ check treatment Filtered Untreated or Other_ ❑ REPEAT SAMPLE Previous coliform presence Lab # Date / ! Total Free) ❑ RAW SOURCE WATER Source # FS1 ❑ ❑ Total Coliform ❑ NEW CONSTRUCTION or REPAIRS ❑ Fecal Coliform ❑ OTHER (Specify) REMARKS: (LAB USE ONLY) DRINKING WATER RESULTS ❑ UNSATISFACTORY, Coliforms present ❑ SATISFACTORY, Coliforms absent REPEAT ❑ E. Coli present E. Coli absent SAMPLES REQUIRED ❑ Fecal Present Fecal absent ❑ OTHER LABORATORY RESULTS TOTAL COLIFORM /100 ml E. COLT /100ml FECAL COLIFORM /100 ml PLATE COUNT /ml ANOTHER SAMPLE REQURED SAMPLE NOT TESTED BECAUSE: TEST UNSUITABLE BECAUSE: ❑ Sample too old ❑ Confluent growth ❑ Wrong container ❑ TNTC ❑ Incomplete form Turbid culture ❑ Excess debris SEE REVERSE SIDE OF GREEN COPY FOR EXPLANATION OF RESULTS LAB NO. (7 DIGITS) DATE, TIME RECEIVED RECEIVED BY DATE REPORTED LABORATORY: REMARKS DOH 305,-M (REV. 4W) WATER SUPPLIER COPY INTERPRETATION OF RESULTS FOR DRINKING WATER The analysis performed on this drinking water sample is an examina- tion for the presence of coliform organism., in the A-a:c-: and 7Jicates the bacteriological quality of the sample. The p,asen�e of coliform-, organisms is used by health organizaticns .vorldwloe as an indicator for the possible presence of other disease ca.,sing organ sms. REPORTING OF RESULT` . Group A Public Water Systems must report the results of Drip:King Water Analysis to the State as specified in WAC 246-29C- ;*Q. SATISFACTORY RESULTS: The absence of coliforms from a+;y sample ,s sat sfact-•ry. P-. r-;er system maintenance and bacteriological monitoring should: be con- tinued routinely to insure the safety c:f the water supply. UNSATISFACTORY RESULTS: Any coliform presence is unsatisfactory. The presence of coliforms indicates the system is :-.ot pr;Ierly protected against contamination and may be unsa'e for h_ nan con- sumption . Unsatisfactory samples should be "vesti_ated 1"11VIEC,l- ATELY and rppeaj samples submitte . Contact your local health department or DOH Regional Office for assistar.ce in de:,(mining the source of contamination and corrective procedures. When fecal coliforms or E.coli are reported present in a sarnp,e, Ihiic IMMEDIATE ACTION REQUIRED by a Public System is. 1. Investigate to determine the cause and correct the situation. Your local 'health department or DOH Regional Office can assist you. 2. Submit repeat samples as specified in WAG 2_'E-290-480. 3. Publicly notify the users of public water systems as speci- fied in WAG 246-290-480. 4. Contact your local health department or DOH Regional Office as specified in WAG 246-290-480. TEST UNSUITABLE: Resample Immediately "Confluent Growth" means bacteria have grown into a continuous mass which makes counting impossible. "TNTC" means bacteria are too numerous to count. "Excess Debris" means that particulates in the water interfere with the interpretation of test results. ''Turbid Culture" means an overgrowth of other bacteria can interfere with coliform analysis. If any box indicating an unsuitable test is checked, the presence of coliform bacteria could not be determined and a new sample must be obtained for testing. RESAMPLE: Sample too old. (Sample to be tested must be received within 30 hours). Not in proper container. (Bottle to be used for testing must be purchased from a certified lab within 6 months.) Insufficient volume. (Sample must be at least 100 ml) If not tested, a new sample must be submitted for analysis. FOR ADDITIONAL INFORMATION: Contact your local health department OR the laboratory where this sample was tested OR the Department of Health, Drinking Water Program Regional Office.