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TIME RECEIVED 1N L 2 -,,(Do <br />CENED BY: ��4 <br />'Routt County Department of��Looc <br />v 'nmental Health <br />REPORT NG FORM FOR BAC ICAL ANALYSIS <br />SA-NIPLLR: PLEASE FILL OUB' 011E FORM <br />DATE COLLECTED Li <br />PWSID #: COUNTY: <br />(Public Water System Identification N- u ber) <br />SYSTENVESTABLISKtii TENT NAIti E: <br />SYSTEM ADDRESS: <br />mA LING ADDRESS C <br />CONTACT PERSON: ���r,�b{ �"' _ PHON <br />SAMPLE COLLECTED BY: <br />WATER TYPE: RAW[ ] GWR [ ] CHLORINATE: <br />SAMPLE . <br />'Dnr&Trr• i U ; <br />SAlWI LE TYPE,: <br />ROUTINE [ ] <br />r u r� r _ _ �: ► LMM� <br />Y STATE Z <br />( � 23 -4`l FAX: C. ) CLC. -CO ►vl <br />0>6 +- t to !'� <br />TME COLLECTED:' am/pm <br />] OTR TREATMENT [ ] explain <br />CHLORINE <br />-DL•`-QTTITTAT-: <br />For Laboratory Use lOnly Be <br />LABORATORY SAMPLE # '-44-�Jfr?�i-. <br />C ONMENI'S : <br />PARANLETER RESULT ' <br />Coliform, TOTAL "(Abseut/Present) <br />Colifonn, E.COLI (AbsentTiesent) (�c <br />OD = Outdated - Please resample <br />LA = Lab Accident - Please resample <br />Absent = Coliforn not detected I. <br />Present = Coliform detected <br />J3evrewed &-Approved by <br />Routt County Environmental Health Dept. <br />136 6`b Street <br />PO'Box 770087. <br />Steamboat Springs, CO 804'17 <br />L24056-1505201031 <br />SPECIAL PURPOSE [ ] <br />?iv This Line <br />VED IN LAB ORATORY APR / 0 <br />YSIS I DATE LAB METHOD <br />V-11 <br />n 4IA� Colilert 24-hour - - <br />Colilert 24-h6iz <br />Title <br />Date <br />Phone '(970) 870-5588 <br />Fax (970) 870-5404' <br />Page 13 of 14 <br />