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TIN, UCEIVED IN LAB RED YED BY: `? (•t _ <br />Routt County Department of Environmental Health <br />REPORTING FORM FOR BACTERIOLOGICAL ANALYSIS <br />SAWLER: PLEASE FILL OUT ONE FORM - FOR EACH INDIVIDUAL SAMPLE SUBMITTED <br />DATE COLLECTED 4 / 15 /. 10 <br />PWSID #: COUNTY:_'?R cx zd7 <br />(Public Water System Identification Number) <br />SYSTEM/ESTABLISHMENT NAME:,. h s ,? <br />SYSTEM ADDRESS: <br />MAILING ADDRESS TM 1&3 hla -7d X&a'?t Y Ff Cpl S STATE CO ZIP a <br />CONTACT PERSON: HONE: -20J 09 7 •Fg,-?;FAX: (Q p) <br />TIME COLLECTED: 315 anV f?i <br />SAMPLE COLLECTED BY: IJIICJ?r <br />WATER TYPE: RAW [ ] GWR [ CHLORINATED [ ] OTHER TREATMENT [ ] explain <br />SAMPLE CHLORINE <br />POINT: RESIDUAL: m'9/L <br />SAMPLE TYPE: ROUTINE [A REPEAT[ ] SPECIAL PURPOSE [ ] <br />For Laboratory Use Only Below This Line <br />LABORATORY SAMPLE # r DATE RECEIVED IN LABORATORY - :- <br />COMMENTS: <br />PARAMETER <br />Coliform, TOTA?_(Absent? esent) <br />Coliform, E.COLI (Absent/Present) <br />RESULT <br />ANALYSIS DATE <br />f alu <br />LAB METHOD <br />Colilert 24-hoi <br />Colilert 24-hour <br />Ju? I r O10 <br />Reviewed & Approved by Title Date <br />Routt County Environmental Health Dept. Phone (970) 870-5:88 <br />1366 th Street Fax (970) 870-5404 <br />PO Box 770087 <br />Steamboat Springs, CO 80477 <br />OD = Outdated - Please resample <br />LA = Lab Accident - Please resample <br />Absent = Coliform not detected <br />Present = Coliform detected