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Sep 22 2010 2:53PM HP LRSERJET FRX P.1 <br />TI.IVIE i CEMD 'IN LAB UI) RE CEO . ED BY: <br />Route County Department of Environmental Health <br />REPORTING FORMFOR BACTERIOLOGICAL ANALYSIS <br />SAMPLER: PLEASE FILL OUT ONE FORM' - FOR EACH INDWIDUAL SAMPLE SUBM=D <br />DATE COLLECTED <br />PWSID COUNTY- <br />(Public Water System Identification Number) <br />SYSTEM/ESTABLISHMENT NAME:; <br />SYSTEM ADDRESS: 6YA nL?l L. <br />MAILING ADDRESS 77 CITY STATE &d ZLP <br />CONTACT PERSON: n[LzWj PHONE: 7u ,'97 kYoVpAx: L7 aal ?l l <br />SAMPLE COLLECTED BY., TIME COLLECTED: /gOCJ , ant/ m <br />WATER TYPE: RAW[ ] GWR [A CIMORINAT13D [I OTHER TREATMENT [) explain. <br />SAMPLE CHLORINE <br />SAMPLE TYPE: ROUTINE [ ] REIDEAT [ ] SPECIAL PURPOSE [ ) . <br />For Laboratory Use Oydy Bekiv This Line <br />LABORATORY SAMPLE # DATE RECEIVED ZN LABORATORY / t <br />COMMENTS: SEP 2"1 2m <br />PARAAnTER RESULT <br />Coliform, TOT. (A1; en r ent) _ <br />Coliform, E. COLI (AbsenVPresegt) <br />OD = Outdated - Please resample <br />LA = Lab Accident -Please resainple <br />Abseat = Cohfoimi not detected <br />Present = Colifozxn detected-, <br />Reviewed & Approve4 by <br />Routt County Environmental Health Dept. <br />.X36 6`h Street <br />PO Box 770087 <br />Steamboat Springs, CO 80477. <br />ySIS ATE <br />OD <br />lilext 24-Dour <br />Colilert 24-hour <br />S?p $„ 2o1Q <br />Title Date <br />Phone (970) 870-5588 <br />Fax_ - (970) 870-5404