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Sep 22 2010 2:53PM HP LRSERJET FRX P.3 <br />T11E RECEIVED IN LAB : a? RECEIVED BY: <br />Ro utt County Department of Environmental Health <br />REPORTING FORM;FOR BACTERIOLOGICAL ANALYSIS <br />SAMPLER: PLEASE FILL OUT ONE FORM'- FOR EACH INDIVIDUAL SAMPLE SIMM1 1 "I'ED <br />DATE COLLECTED f Zf- r. t.p <br />PWSID COUNTY:q,,o - <br />(Public Water System Identification Number) t ( n <br />SYSTEMJESTABLLSHNIENT•NAME: <br />SYSTEM ADDRESS: <br />a STATE?ZIP, <br />MAII.iNG ADDRESS f + t <br />iaizz <br />CONTACT PERSON: NONE: {?7po?cAX: ?? ??? <br />SAMPLE COLLECTED BY: T/q TRYM COLLEC'T'ED: /?13a a?n/ r? <br />WATER TYPE: RAW [ ] GWR Pq CHLORINATED [ ] OTHER TREATMENT [) explain <br />SAMPLE <br />CHLORINE <br />SAIvIPLE TYPE: ROUTINE [ ] REPEAT [ ] SPECIAL PURPOSE [ ] , <br />Far Laboratory Use Only Belbiv This Lire <br />LABORATORY SAMPLE # DATE RECEIVED IN LABORATORY <br />- -aI <br />CON MNTS: <br />PARAMETER RESULT <br />Coliform, TOTAL (Absen>_e_ <br />Coliforrri, E•C bs went) <br />01) = Outdated - Please resample <br />ILA = Lab Accident - Please resample <br />Absent = Coliform not detected <br />Present= ColVonn deflected ?n <br />Reviewed & Approved <br />Routt County Environmental Health Dept. <br />136 6th Street <br />PO Box 770087 <br />Steamboat Springs, CO 80477 <br />A.1\TALirSIS DATE LAB METHOD <br />SEP 22 2010 olilert 24-hour <br />SEP 2" 2 1010 Colilert 24-hour <br />i <br />44'jffc`? ?SE V1 2010 <br />Title Date <br />Phone (970) 870-5588 <br />Fax- (970) 870-5404