HomeMy WebLinkAboutWTR2702785 WTR-27-2785
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Laucks Testing Laboratories,Inc.
940 S.Ham y Seattle.WA 98108
WATER BACTERIOLOGICAL ANALYSIS
SAMPLE COLLECTION:RETD WSTRLKJIGNS ON BACK OF GwEEr.ROO COPY
i a NHeewaene BAE nol Ioibbee,BBRIPM BlN a nMo1W.
MOATDATE COLLECTED TAME COLLECTED COUNTY NAPE
DAY YBM Z S
�U S OC_ ❑ M . �F
ITYPE OF SYSTEM F PUBLIC SYSTEMM.OOMPLElE
'. �PUaI� _ CINC.E GROUP
mmDUN
ABIwwM+r.yA.ey --
NAME OF SYSTEM
lECFC lOd7EINYAFIE S/1PIE 7SYSTEM
NO.
INGSAMPLE COLECTED W(Nwo) OYMER0MOR.:NOW)
►tit. w 6 : �?I lu>tt
80URCE 1 YY�EEiGLyRDUNDNMTER UNDER SURFACE INFLUENCE
��ACE ❑M MELD ❑SPRING ❑N AYE EDa w TNERIlON
aSD 1fTOc B►MIM Full m BBB ZIPNow.Adam COM)
IUfS (5r^-5v w•�
TYPE OF aMPLF(dM o*onw BAs ooMnm)
i ❑�VATER ❑CNUFaYE(ReYdW._TOY_Fm)
1 do*BAAIIIIEIA +❑FMMBB
❑UnEABIMaOMVB
❑REPEAT SAMPLE
P,,I"aoaum pn LAb A____
DBN —�—�_
[ ❑RAW SOURCE WATER S A C ! i ❑TOM fdtlam
aud
NEW CONSTRUCTION or REPNRS 1 1 ��y.Jl ❑�' Commm
OTHER
11EMARKSf�
BLAB USE ONLY)DRNKM sMTER LESLLr,
Q UNSATISFACTORY.Cosoma TA.BAIK ❑SATISFuA
bwd
REPEAT. ! SAMPLES ❑�pw 0 FAaY ADAAIA
REQUIRED ❑
OTHER LABORATORY RESILTB
TOTALCOl/FORM,_A00 m1 E.COLI 4 flooml
FECAL COUPORM 1100IN PLATE COUNT AM i
ANoTmERSAMPLE REQUIRED it
SAMPLE NOT TESTED BECAUSE TEST UNSUITABLE BECAUSE:
❑Saepw Moo aM ❑CamMnN Faem
• ❑Wp canMYMr (]TNTC
rol
❑IAaampl"Arm L]Twm LWa
❑ ❑EAoaadOW
SEE,REVERSE SIDE OF GREEN COPY FOR EXPLANATION Of RE SEAS
W lq.('OBBTM MTLTRANDENO AECEIVEDBV
'I I
MTf K.PONTrJ 1ABDILAw
f A�
W ATER SUPPLIER COPY _
Laucks Testing Laboratories, Inc.
940 S Harney Seattle.WA 98108 !�
WATER BACTERIOLOGICAL ANALYSIS
SAMPLE COLLECTION:READ INSTRUCTIONS ON BACK OF GOLDENROD COPY I
N kvsVucbo are not followed,UmPle VAR be relented. .�
DATE COLLECTED TICOLLf,C�j1 COUNTY NAME
' TH DAY /^vEcAR ILL fY-hl/ I� I
1 Z3 l 1 SAM ❑PM
1
{TYPE OF SYSTEM I IF PUBLIC SYSTEM,COMPLETE:
u PUBLIC Cl GROUP
GROUP
❑INDIVIDUAL. I.D.ND. -7 I 8 L SAY B
I�ukv r ma..:c
NAME OF SYSTEM
C It or
AIECXIC LOCATION WHERE SAMPLE COLLECTED TELEPHONENC)
-0 i► DAY Yar) 2 3 S'- 26 G/G !tM
EVENING
SAMPLE COLLECTED BY:(Na,,,*) SYSTEM OWNERIMGR.:(Nr )
Yh. vac r►►eimcc 44- S/
SOURCE TYPE GROUND WATER UNDER SURFACE INFLUENCE
} []SURFACE []WELL w ❑SPRING ❑PURCHASED w COMBINATION
WELL FICLD INTERRE arOTHER
SEN TO: Prot Full Name.AW,ewl end➢P COW)
Iasr eA-by LA Ay
• TYPE OF SAMPLE(dwk m1Y One in MIs cdumn)
❑ROUTINE p Cblwmateo(Resxtwl To,al Free)
DRINKING WATER _--
check treahrlem ❑hllweO
❑REPEAT SAMPLE
Prsvaw cdgom,P:eaerKe Lab N__
DeN__/_/_
❑RAW SOURCE WATER So fl ❑1bwc EIwm
19 NEW CONSTRUCTION REPAIRS ❑Fecal CoIIFOrm
❑OTHER(SPecM1.-_— _�^�O`� Q.��---- (LAB USE ONLY)DRINKING WSW RESULTS— —
❑UNSATISFACTORY,Cold m pneent ❑SATISFACTORY.
DAnsFA aWenl
REPEAT ❑E.Coll present ❑E.Cap absent _
SAMPLES Fe W prew,1 ❑Fecal absent
REWIRED ❑
OTHER LABORATORY RESULTS
TOTAL COU RM _ /' 100 rnl E COLI A It DO MIL
FECAL COLIFORM_/100 ml PLATE COUNT _ /ml
ANOTHER SAMPLE REOUIRED
SAMPLE NOT TESTED BECAUSE-. TEST UNSUITABLE BECAUSE.
❑Sample too clo ❑Ca,kuent gmwtb
❑Wrong contaner ❑TNTC
❑Incomplete Iwm ❑TurbM culture
❑_._____— ❑Excess Wbne
SEE REVFRSE SIDE OF GREEN COPY FOR EXPLANATION Of RESULTS
W W.IT DIGIT& DATE. RE�N,ED RE D_Bv
QS(l(s 'l�(og '7 �tr/
DATE REPOR7Eo LNOC$wrow
AeNrAlte
pow xeam WA rE
WA F.R SUPPLIER COPY
— 1
Laucks Testing Laboratories,Inc.
940 S.Harney Seame,WA 98108
WATER BACTERIOLOGICAL ANALYSIS
SAMPLE COLLECTIONS READ INSTRUCTIONS ON BACK OF GOLDENROD CM
H InstruDNone am not followed,sample WIN be mil-tad.
i
DATE COLLECTED TIf.1�COL COUNTY NAME '
MO9NfN DAY PEAR /p�
Z iw1 AM ❑PM k l lr T V
TYPE OF SY:TEM IF PUBLIC SYSTEM,COMPLETE:
PUBLIC
❑INDIVIDUAL I.D.ND. lk
id,
/ GIZ.(1j BE GRBOUP
uen.e�y n.aerM
NAME OF SYSTEM 1
� i C FNfvY'l
TIFIC LUGPJNYa1 E SAMPLE COLLECTED TELEPMONL NO.
it �` K y o f{ Z DAY Zr V
EVENING, ,
S�1AM,PLE COLLECTED BY:(Name) SYSTEM OWNEWMGR.:(Name)
11` WE7 4cl
SUUACE TYPE GROUND WATER UNDER SURF INFLUENCE
E SURFACE ❑WELL or [IRIN SPRING 0 PURCHASED or K COM&NATXIN
A WELL FIELD INTERTIE or OTHER
. SEND[iE TO:fFinnt
�Y1GName,Add ias and ZIP Cowl
„
10fS vIxAIII L.VAt�
k wAv.iRpTon S'S
TYPE OF SAMPLE;CN k only one m�NTIe column)
RIINNK NE
DR NG WATER L Chlonnated IReadu.i 1Dta1 Feel
check Ireetmem ❑
C� Firm io
Untreated or ether.
LJ REPEAT SAMPLE —_
Prallou3 rN40 ,p '. Lab e
Dale
❑RAW SOURCE WATER Source It O m ❑Total Co04nrm
❑NEW CONSTRUCTKNJ or REPAIRS ❑Fecal Cadom,
❑OTHER(Swmy)_ & fi —. _.
RE KS:
k tat� t�,o 8y
ILAB USE ONLY)DRINKING WATER REBWLTB
❑UNSATISFACTORY,Coleorms g=EW.
❑SATISFACTORY.
REPEAT E.ColiCOlilorrr ebxnt
SAMPLES ❑ IxefwntREQUIRED ❑Fecal Pment
OTHER LABORATORY RESULTS _—
TOTAL COLIFORM _1100 m1 E.COLT _ /100 ML
FECAL COuFORM /100 ml PLATE COUNT_ _ /ml
ANOTHER SAMPI E RFOUIRFD
SAMPLE NOT TESTED BECAUSE: TEST UNSUITABLE BECAUSE:
❑Sample too ow ❑Cwfty t growth
C Wrong container ❑TNTC
❑Incpmplate Iona ❑Turdd Cullum
❑—._____ ❑Excew debris
SEE FIZVERSE SIDE OF GREEN COPY FOR EXPLANATION OF RESULTS
LAB No.IT DOTS, DATE,THE RECEIVED RECErvED B�
WTE REPOInE LAWRKIDIN: _, M
'{ l
aFlYla f
tan e]600 FIaY YRI
WATER SUPPLIER COPY
f —
i Laucks Testing Laboratories, Inc.
' M S.Harney Searle.WA 98108
WATER BACTERIOLOGICAL ANALYSIS
SAMPLE COLLECTION:READ INSTRUCTIONS ON BACK OF GOLDENROD COPY
It itµVuotions BIe not followed,sampW will be rejected.
.`t
DATE COLLECTED E COL ED COUNTY NAME
MGNTn DAY YEAR `
9 �z 3 9 9 AM PM
` TYPE OF SYSTEM IF PUBLIO SYSTEM.COMPLETE:
t'
.. ❑INDIVIWAL I.D.Na. `7 If Q S L CI r!`GB UP
ewr mM1 I IDUAL O &
NAME OF SYSTEM
l E �- nF �cr � I
S URC LOCATION SAMPLE COLLECTED TELEPHONE NO
DAY Y[r 2 3.5—
EVENING
1 SAMPLE COLLECTED BY(Names SYSTEM OW (Name)
rn•
SOURCE TYPE GRWNO WATER UNDER SURFACE INFLUENCE
❑SURFACE []WELL or ❑SPRING ❑
eeaanPURCoHAWELL FIELD INTERTIESEC)SENiLlff THER
(Print o
yLP Cde)IGts r1-,qJIV 1444,
_
W4nJ.J
TYPE OF SAMPLE(Clwck only err In ,is column)
❑ROUTINE
DRINKING WATER ❑Chlonnated lResMual:`_Tdtl.__Fn»I
check treatment ❑Fiaered 1
❑Unh KW or Other -
❑REPEAT SAMPLE -'
Prev cdrlorm preeence Lap
GBNtr
RAW SOURCE WATER soumee❑$ m ❑Tpty Call.
NEW
OTHER ISpe CONSTRUCTION�/�,^� � ❑F*oW CPMIpm
R_ 3ol 7 h o• 88v/o
(LAB USE ONLY)DRINKING WATO 1QOILT8 I
❑UNSATISFACTORY,CdltDmle present El SATISFACTORY
REPEAT E. 1
Cd� C."'..abeam
SAMPLES ❑ Present ❑E.Cdi ebrnt
REQUIRED ❑Fecal Prawn: ❑Fecal abeam
OTHER LABORATORY RESULTS
TOTAL COLIFORM _/:DD mI ECOLI _/100ML
FECAL COLIFORM _/100 ml PLATE COUNT_/ml
ANOTHER SAMPLE RE RED
SAMPLE NOT TESTED BECAUSE: TEST UNSUITABLE BECAUSE'
❑SampM Im dd ❑CmlWarlt growth
❑Wrong cme,wr ❑TNTC +7I
❑In Pwe tone ❑Torpid cu0ure +
❑_.--_—_ ❑Eacaee None
SEE REVERSE SIDE OF GREEN COPY FOR EXPLANATION OF RESULTS
UB NO P OIGIT51 DATE TIME cENED
� _ n // yy��__ RECEIVED av
OR/6 4 + - 71a31`�`7 a UG
i .
DATE REPDAR:D lAepRAT011M
\L
a •rt
IaMM.a y—�o 3
ew NAEe+wY see
WATER SUPPLIER COPY
Laucks Testing Laboratories, Inc.
940 S.Harney Seattle.WA 98108
WATER BACTERIOLOGICAL ANALYSIS
SAMPLE COLLECTION:READ INSTRUCTIONS ON BACK OF GOLDENROD COPY
N IneWCNont ere not followed,ample WIN be re*cte&
DATE COLLECTED 1 COLLEf.'�D COUNTV NAME
MONTM WY Y p R \V 1L
Z 1 AM ❑/''M f� 1 h�_
TYPE OF SYSTEM IF PUBLIC SYSTEM,COMPLETE
PUBLIC
e C E GROUP
❑INDIVIDUAL LD.No. U O )
1.a Inee.ce ® B
NAME OF SYSTEM r
SPECIFIC Lk%wT IiRIE SAMPLE COLLECTED TELEPHONE NO
F 2 .
I'LC Nyb y DAY Yty 2GY6
EVENING
&LE COLLECTED SY(Neme) SYSTEM OWNER GR.:IName)
IfA S1ra
SOUR(:E TYPE GROUND WATER UNDER SURFA E INFLUENCE j
❑SURFACE []WELL or ❑SPRING ❑PURCHASED or'L COMBINATION
WELL FIELD INTERNE POTHER
• SENp RSpOFl\T IPnOt Full Nama.Aeeroee a� Zip Cotl )
�11 !',MIDI tj III
toss laij Iq b7- y /
Prtr wsv TH
TYPE OF SAMPLE(CM k only one in a,le column)
❑RWIINE nn Chloeleo(ReeMuar Total Fee)
DRINKING WATER ❑ --- -- -
check treatment ❑Faereo
❑Umreatetl or Other__—
❑REPEAT SAMPLE - -
Preywus coloorm Presence Lab e
Dot*
❑RAW SOURC Wr TER SW s Q m ❑Total(304orm !
NEW CUNSTF ICTIONy,(y R N�1yS�' ❑Fe Comorm j
❑OTHER ISPeoBY)_1fL: 3. __--_____
AR _LyQ p 8 41n f
(LAB USE ONLY)ORHO NG WATER RESULTS
1
❑UNSATISFACTORY,Cokfams present ❑SATISFACTORY,
REPEAT E.Coll Cdilomr WNre
SAMPLES ❑ present ❑E.Cdi absent
REWIRED ❑FecN preasr,l ❑Fecal absent
['OTHER�LABORATO�RY RESULTS
TOTAL COLIFORM___ /t0O ml'A 1 c COLT_ /7\ tOO ML
FECAL COLIFORM_1100 ml PLATE COUNT RBI
ANOTHER SAMPLE REQUIRED
e i
SAMPLE NOT TESTED BECAUSE. TEST UNSUITABLE BECAUSE
❑Ssmpw too do ❑Coft t rt grow
❑W-V caNmrter ❑TNTC
❑kroornplme form ❑Turlxo culture
El--- -- _ ❑Ekoess oe6m
SEE REVERSE SIDE OF GREEN COPY TOR EXPLANATION OF RESULTS
LAB NO O 01(iff 1 oATE.TARE IWG RECEIVEDBY
DATE REPORTED LUORATOR, y
9 1 �L
? J y
RC WY8
oW tel mPelEv Vfh
WATER SUPPLIER COPY
Laucks Testing Laboratories, Ir-c.
940 S.Harney Seattle.WA 981 of '")
WATER BACTERIOLOGICAL ANALYSIS
SAMPLE COLLECTION:READ INSTRUCTIONS ON BACK OF GOLDENROD CJPY
If fnsGucEans as,not followed.sample Will be r.j.l,ted.
DATE COLLECTED T COLL COUNTY NAME
MONTH OAv I. tv
Z I� 10AM ❑PM k t Yl
1pTYPE OF SYSTEM IF PUBLIC SYSTEM,COMPLETE:
Lti PUBLIC
❑INOR9WAL / 8 CIRCLE GROUP
L..e.mN,�wa AL r\CJ• EI
NAME OF SYSTEM —
(Z
CFICLOGTKNYA oOECD TELEPH
ONE,IKE NO
uyb *d S' DAY Wr 23s•?GVb
i
I
EVENING
} SAMPLE COLLECTED BY)Name) SYSTEMQW.NERIMOR.:)Name)
►h1LQCTµ� c fn S/ �, I
SOURCE TYPE Lj GROUND WATER UNDER SURFACE INFLUENCE
[I SURFACE [DWELL or ❑SPRING ❑PURCHASED or Ip"BINATION
WELL FIELD INTERTIE or OTHER
SE rPOFq TO (Print F I Name,Agoreiia yq ZIP Coda)
a It 4j.
Ir i S G/AD --
tr� •.T �pST TYPE OF SAMPLE(chock only one In mis colunn)
❑ROUTINE
DRINKING WATER ❑Chlonnatad(R.,,., Total F.)
check treatment ❑Filtered
❑Untreated or OIRx _
❑REPEAT SAMPLE
Prevroua colRorm presence Lab a_
Une
rqo❑fR RAW SOURCE WATER Spl41:e a u I ❑Total cw.
tC NEW CONSTRUCT IOy�y � —1 Fecal Caabrm
❑OTHER ISpeo1N)_ B
MARKS _
07 p Q�'--
A A Al IA70 vv�'
(LAB USE ONLY)DRINKING WATER RESULTS
❑UNSATI$FACTORY,Cdifcrtns present ❑CATISFA TTOaIn RY,
ent
REPEAT ❑E.Cob present ❑E.CoL absent
SAMPLES
REQUIRED ❑Fecal present ❑Fecal absent
OTHER LABORATORY RESULTS
TOTAL COLIFORM 1100 ml E.COLI_ /100 ML
FECAL COUFORM __ /100 ml PLATE COUNT /ml
ANOTHER SAMPLE REQUIRED
SAMPLE NOT TESTED BECAUSE-. TEST UNSUITABLE BECAUSE
u Sample tco oa ❑C'maUer11 WOMI,
❑Wrong contmem ❑TNTC
❑IncpmplNe torn ❑TurbW culture
❑—____ ❑Eattss debris
SEE REVERSE SIDE OF GRLASEEN
7 r?MIT$) EENCOPY FOR EXPLANATION OF RESULTS
MTE.TIME RECE,,NS) ME EM BY
0.6
0AW FISPORTS, ILAapRlppRy
ee mmRW Ne
WATER SUPPLIER COPY
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,Eemple will be Fuiected.
DATE COLLECTE'7777
AME
LWY
Z3 9AmnG
I TYPE OF SYSTEM IF PUBLIC SYSTEM.COMPLETE.
PUBt IC
❑INDIVIDUAL LD.N0. 7 CI GROUP
Mwa o-yt nngwcei S B
NAME OF SYSTEM
o r1
t l o G is t1fo��
L �C LDC I ATEIE SAMRE COLLECTED TEIEPNONE NO.
Ira DAY
DAY
* EVENING
SAAAWLE COLLECTED BY(Name) SYSTEM OWNERlMGR.-(Name)
�A- SSG
SOURCE TYrELJ GROUND WATER UNDER SURFACE INFLUENCE
❑SURFACE D WELL FIELD❑SPRING ❑PURCHASED p COMBINATION
WE w
INTERTIE POTHER
TO IP'nt F I Name,AEdnnP;arp ZP Cods)
o r S G iAD 044.4
C;;n ce T BOJ-S
w,M�NPiOa
TYPE OF SAMPL.E(check arty OM in this column)
❑ROUTINE
DRINKING WATER ❑Chlorinated(Rowual, To, _Froe{
check tnud~t ❑Fina --
❑Unbeetm p On w
❑REPEAT SAMPLE -- ---—
PmYrous colRam pm,wn Labe
Dete
❑RAW SOURCE WA�TTy_!ER,� aw Sa e� m ❑TOW QAI..
X NEW CONSTRUC w�W y(y/� ❑Foul Colibm
❑OTHER ISMIN)_
ns �.__ QE.L \
(LAS USE ONLY)DRINKING WATER RESLIITs
' ❑ NSA VAC'
Coll rms Praeenl ❑SATISFACTORY,
1 REPEAT E.Coh Cdifpme eDfent
j SAMPLES ❑ Pm80n1 ❑E.Cols absent
REWIRED ❑PocM Pmsent ❑Feul abe«,t
OTHER LABORATORY RESULTS
TOTAL COLIFORM n00 m1 E.COLT
00-AL
FECAL COLIFOHM /100 m1 PLATE COUNT !ml
ANOTHER SAMPLE F,EOUIRED --
SAMPLE NOT TESTED BECAUSE. TEST UNSUITABLE BECAUSE'.
❑Sample too old ❑Canthront growth
❑Wrwq container ❑TNTC
❑IncomPbp torn ❑Turw culture
❑—'-- ❑EAtess dsbns i
SEE REVERSE SIDE OF GREEN COPY FOR EXPLANATION Of RESULTS
LAB NO P DKWM mw TIME RE RFCE.. gv
v��roAi� �3 �,, �; �� y�,
DATE LABORK TOR I
mH�ee..+u
WATER SUPPLIER Copy
— 1
Laucks Testing Laboratories,Inc.
940S Harney Seattle.WA 98108 ..i
WATER BACTERIOLOGICAL ANALYSIS I
SAMPLE COLLECTION.READ INSTRUCTIONS ON BACK OF GOLDENROD COPY
R instructkm are not followed,sample will be miected.
DATE COLLECTED TICOLLL=D COUNTY NAME
MONTH OAv TEAR �(Q-�}/�
9 23 9 AM PIM 1
TYPE OF SYSTEM IF PUBLIC SYSTEM,COMPLETE:
TJ PUBLIC
❑INDIVIDUAL O 11,
I CIRCYE GROUP
1.Dory'Nance , kl•Y'1
NAME OF SYSTEM
i
�E P
IRC LOCATION RE SAMPLE COLLECTED TELEPHONE NO.
:2c // sy` 7 DAY jr) 2-?-2`Y6
EVENING I
SAMPLE COLLECTED BY:IName) SYSTEM OWNERAMGH.:(NAme)
Mae tt eA S/cn
SOURCE TYPE GROl1ND WATER UNDER St'RFACE INFLUENCE
SURFACE ❑SPRING ❑PURCHASED w Z COMBINATION❑ ❑WELLw
WELL FIELD INTERTIE wf1NER
SEND 7P{�RTJO Ifrint Full NeZ _m
z Code)
/OSS y�gbx
/Z a-I 7Y.i7 w..Tw.980 f f'
TYPE OF SAMPLEIcKsck only wu In Mia column)
❑ROUTINE DRINKING WATER ❑Chlorinated IRePdual.__Total __..Fes)
cMCM tmetment ❑Fiaered
❑Umresud w Other
❑REPEAT SAMPLE
Previous conform Presence Lab a_
Date
❑RAW SOURCE WATER Samce.l-l = ❑Total CWINI rn i
®NEW CONSTRUCTION w REPAIRS (� ❑Fetal Commm
❑OTHER(SPaaNI_ -
RENIARKS f.—'-y
ILAS USE ONLY) DRINKING WATER RESULTS .y
❑UNSATISFACTORY,Col;fcrms we6em ❑SATISFACTORY
REPEAT Colibrms sbsre
SAMPLES ❑E.Cori present ❑E.Coli absent
REOU19ED ElFecal pr9eent ❑FB l at a nt
I
OTHER LABORATORY RESULTS
TOTAL COLIFORM Iioorn1 E.COLII�_ /tpp(�ML
FECAL COLIFORM__/100 ml PLATE COUNT-Y4-Anr
ANOTHER SAMPLE REQUIRED`;AMPLE NOT TESTED BECAUSE. TEST UNSUITABLE BECAUSE
❑Semple too old ❑Confluent growth 1
❑Wrong cpmeiner ❑TNTC I
❑hCompwo form ❑Turbd Cullum I
❑ ❑E.eeee debne
SEE REVERSE SIDE OF GREEN COPY FOR EXPLANATION OF RESULTS
LAB NO.R Dam PATE,raAE RE FECENED By
DATE REPOWr IA9pRATOW
I
t) Y
REEIMrfs
td.]m mt plV aVl
vV A Tc R SUPPLIER COPY
Short Plat (SHPL# )
REQUEST FOR PROJECT# Prelim.Plat (PP# )
CAG# )
To: Technical Services Date —/— ff WO# Green#
From: Plan Review/Project Manager V L L ya'y%&/tr
Project Name AsyBVRN CONOpMIA/ /n/IVIhS
(7a<Auaeten maa)
Description of Project: L N [ P
�� �4T�a N OF f RR frDiWAL r e w-r,s.L �
MA Tff fAArr1ARAAL,,iv,6 AvP
f
Circle Size of Waterline: 12" Circle One: Ne or Extension
Circle Size of Sewerline: ® 10" 12" Circle One: New or ztension
Circle Size of Stormline: 12" IS" 18" 24" Circle One: New or Extension
Address or Street Name(s) SO i
Dvlpr/Contractor/Owner/Cnslt: /�vQMS%Fdd Cp.v> ,(yCrpN
nacRva Ica 1,=)
cd•y�7XvcTron/ BvQ�vs?F,� �'a ST��c'+ � pOj fN6�Nft�S ?NC.
Check each discipline involved in Project Lir Drwg #of sheets per discipline
pQ Trans-Storm G ❑
(Road-ay/Drainage) 701r site unproremcns)(include bann none)
(include TESC sheer)
❑ Transportation (SiuWindon.Chamcliudon.Ughling) ❑ Cl
�Q Wastewater ❑ ❑
Sanuary Sc-el Main(include bmin
Water (Mains.VA) =.Hydruis) ❑ ❑ to
(Inemdewmpcme b Honiwnu)Ccl SheeW
❑ Suface Water ❑ ❑
Imprdvements ( L )in<wdc bat in name)
TS use Only ITD-q R-3W5
WWP- a7 -97S5
wTlL-A? 3745
PAR - a7- A7 875- or�lt�
Approved by TSM Date:
r ( I
Laucks Testing Laboratories,Inc.
940 S Harney Seame.WA 98108
WATER BACTERIOLOGICAL ANALYSIS
SAMPLE COLLECTION:READ INSTR CTIONS ON BArX OF GO DBWOD COPY
N IM6WtlORa Meal not III'- ,amHpla WIN be nyuly.
DATE COLLECTED TIME COLLECTED COUNTY NAME
N n, oM r6M R /: ('
®AM
ffPE OF SYSTEM IF PUBLIC SYSTEM.COMPLETE:
(ll 1BUC CURIF
` WDIVI d.L I.D.ND. I l'7 L�J Ba~
I..Iw oNy,an iAney
NAME OF$YS7E11
SPEGRCLOCAIONWHERE 8AMPLE I%ALECIED TELEPHOMENIX —� 1
DAYI`ler) yja
T.` Z EVENING
.MMna1 SYSTEMOWNERAOR.:0"") {
saincETYPE WATER UNDER SURFACE INFLUENCE
C]SURFAM [])NELL FIELD �INTERRE ar ❑ nD" .
SENDRE�QRT TQC IPma RA Na A.ACSN OW Zip C0* i.
TYPE OF SAMPLE(d 0*a n Eu mYmR)
f_;ROUTINE
-DRINKING WATER ❑ok*ww Moww'—T4w—Poo
:1*0 DAANMnI --+ FMWW
U WMW v OMm_
�]REPEAT SIMPLE ..
Pmrqua wemrm p,e Lab a
DNA I I
RAW SOURCE WATER Sauna R S m r'� Taal cwNa
�? NEW CONSTRUCTION ar REPAIRS
� F.1 GoAlam
❑OTHER(Spb*)._
W GIBE OMLVIONNON WATER RESULTS
UNSATISFACTORY,Callow PRaaHR
REPEAT ❑E.Cub pmmt ❑E.CWI abeam
REOUREDS ❑FanlplaAMn ❑Few ACAAeI - ,
OTHER LABORATORY RESULTS
TOTALCOLIFORM j, RDDM E.COLT_L/low
FECAL COLIFORM 1100 rM PLATE COUNT .AN
ANOTHER SAMPLE REHIRED
SAMPLE NOT TESTED BECAUSE: TEST UNSUITABLE.BECAUSE:
o oaq '
Wm%m MED
WmRD cani.vwr Q�-
❑❑Inoomp:aW Rpm ❑ ,mw cmum
MT tj 2001
A E REVERSE S10E.OF GREEN IXWv FOR EXP,AS'•' ;' ne PICN70N
uE No.pa*ITM IMELTYEAECENED�6}t FSV&TfOft
� I
' r
DATE REPORRED a ORATOR
aNawxA
WATER SUPPLIER COPY
— I
Laucks Testing Laboratories,Inc. ?�
940 S.Harney Seattle,WA 98108 r- -
WATER BACTERIOLOGICAL ANALYSIS 6
SAMPLE COLLECTION:READ INSTRUCTIONS ON BACK OF GOLDENROD COPY
N NMnw:tiom ere not followed.Sample WIN be milected. r:
DATE COLLECTED TtAFA.COLLE�TbD COUMY NAME
stOn1TR Day vEM
YyTY�P�E���O�F��S�YSTEM IF PUBLIC SYSTEM.COMPLETE'.
IC / CIRCyE GFOINDIVIDUAL
❑INDIVIDUAL LD.N0. ® JL� p B
NAME OF SY TEV1 n Q
C, o 4� RLC.•IY Y_
SPECIFIC LOCATION WHERE SAMPLE COLLECTED TELEPHONE NO.
h c'V rr-a1+ H'�yT•�•,l DAY N�St �.] O -'G oo
* b EVENING(
SAMPLE COLLECTED BY.INema) SYSTEM OWNER/MGR..(NNnot P
t
A� $�t
SOURCE TYPE GRO
UNDWATER WATER UNDER SURF/ACE INFLUENCE
[]SURFACE ❑WELL« ❑SPRING ❑PURCHASED or�j COMBINATION
PpRf,�p WELL FIELD INTERTIE BOTHER
. SELF yLjBE//r F IPmt FxN,Neme.Aderime ell Z Ca 1
n orb t >" 1i
TYPE OF SAMPLEkIwck orAV«ts In 1Nis column) 1
❑ROUTINE DRINKING WATER Celarrnated(R., Mu aal. Total Free)
❑ . -
check treatment ❑Filawd -
❑Untweted«plwr_ _.
❑REPEAT SAMPLE
PEPEAT cAMPL r presence Leo e
Date
❑RAW SOURCE WATER Source Y S i W ❑Total Col't«m
NEW CONSTRUCTO�N nor REEP.A�IRV( 1—J S ❑Fecal Colifa m
❑OTHER(SpecM)_—�
REMARKS:A � �V r r e•\ _,�. 0 1_�.
(LAB USE ONLY)DRINKING WATER REIULft
❑UNSATISFACTORY.Cdl1«ma Pasant ❑$gnSFACTORY.
_ REPEAT C,'a�l°^^s absent
SAMPLES
❑E.Cdi preeant ❑E Col,aDaent
REWIRED ❑Fecal Pra ❑Fwai ahs9nt
OTHER LABORATORY RESULTS
TOTAL COLIFf`RM /ill ml E.COLA _ /1 ML
FECAL COUFORM_1100 ml PLATE C
ANOTHER SAMPLE REQUIRED �f'TT[�((`` ��(��R
SAMPLE NOT TESTED BECAUSE. TEST UNREQUI-t ZEZjj.
❑Sa<nWe too old ❑Cqc"TtPlMNTON
❑mon9 coma'rw. ❑TNWILITV SYSTEMS
❑Inc«nplete form ❑TurD,d Co.,.
❑ ❑F,cess dews
SEE REVFRSE SIDE OF GREEN COPY FOR EXPLANATION OF RESULTS
LAB Ml.(7 DIDRSI DATE.TIME REOENED PEOEMR)BI
%`'i17�`�7�0 12 ?jG� t, SD r;�f�c✓ j
tmTF HFPpeiEq LAODRATORY V t
aEVNxs
pW MPo LW aEV l9Y
WATER SUPPLIER COPY