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Home My WebLink AboutMOUNTAIN PARK ESTATES BLK 11 LT 4Mountain Park Estates Block 11 Lot 4 #017-441-07 MUNICIPALITY OF ANCHORAGE ®� DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION ENVIRONMENTAL ENGINEERING DIVISION 825 L Street - Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT NAME -� PPHO�NE ❑NEW 3� UPGRADE MAILING ADDRESS 1 LEGAL DESCRIPTION / LOCATION NO. OF BE OMS QManufacturer U) DISTANCE TO:Well � t Absorptiarea ,�-� t Dwelling e � on to !` P Materl u�, y in Inside length Width Liq. capaciital . ns IF HOMEMADE: "� _ PERMIT NO � �+ No, of copartmenis eLl Liquid•'�- depth z DISTA O: Well Dwelling P MIT NO. _C Z Q 2 W an ctur Mer Material Liquid capacity in gallons O w J W z i r w � F. Well DISTANCE TO: C (� No. of lines Length of each e - - - -_-__- - Top of tile to finish grade �� 1 3- —s.= 1. U Foundation i Nearest lot line O ,- I Q Total length of lines-� Trench width / incbes Material beneathi lei/ ft U C ` � U is PERMIT NO. Distance betw ep lines Total effective absorption area NO w Length Width Depth -. PERMIT — C7 H W °- Type crib Crib di eter Crib c th Tota fective ab arption are< - W __ DISTANCE &' ell _ Building fonndattpn Nearest lot line r. Depth Driller Distance to lot line PERMIT NO. ]3::D STANCE TO: Building foundation Sewer line Septic tank Absorption areas) OTHER (� PIPEMATERI,LSA-� �A l�nR I, ✓g✓ lw T ' SOIL TEST R TING INSTALL'j iA,ej REMARKS I [APPROVED DATE LEGAL 77-013 (Rdv/3/78) / / "'r'F'E: OF SOIL ABSORPTION '_'r':`;TEh1 11-3: TF:EhIC:F1 t'dI_IMBER OF C,ECPCrtIMS =- d. SOIL. RATING (SQ F=T,'C:,F:).= ':bil=l TF1E PD.71.1IF:ED SIZE OF THE v,MIL A ORF'TICIrd ` YSTErI Is: pN_d ET 1_ " _.t.._ VA == J- Q It— IEE t°-.1 8-3 _1.t..•'t •pct 1 m 9:3 fes:' FA IEE t._. IC:" E=. FK -f- t .g THE L_E"NGTH DIr'IEY.-ISION IS -rHE. LENUaTH CIN FEET) OF THE TRENCH OR DRAINFIEL.D. THE C-Ef'TH CIF' A T'f Er CII CIF: PIT IS THE DID TANC:E BETWEEN THE: SURFACE OF' THE I.ROLINC III'IC: THE BOTTOM OF THE E.,,C:A%A-rION (IN FEET). Tf-ifsRE: I -S NO SET WIDTH FOR TRENCHES. rtlEC GRA',�EL DEPTH IS THE I''1INIr'1UM DEPTH OF GRAVEL. BETWEEN THE OUTFALL. PIPE. 1=II'•11C) THE E,CITT'OI-1 OF 'rFIE E"4`0I=IVATION !:IN FEET::.. F'm U'e N_=@ 1_..N I F1, ICE C. PE F _.t'_ 1 C 9- r-1 VA 1-=': -. 1 W- IES.: J_ 22 W-5; Cs 1:3 F1 N._. M_. a -c P-4 e PERMIT I=1F'F•'L_ i C `A-ff HAS THE F:E.SPCiNS I B I L... I TY TO INFORM THIS DEPARTMENT DURING THE: I NSPEC:T I CIr•d::l CIF t'it•d',•' WE'LL.' ADJACENT AC:ENT TO THIS PROPERTY AND -['HE I.RIrIBER OF RESIDENCES-: THAT THE WELL. WILL. 'SEW'.1E::. _. _.._........... 71..1 NW N d'. LL:11iT PA �-3 IF E: C -r I ND P-A::E F -i F -v R . FZZ C:...: e. -r 9.._1 1 FR C- G'" __. _..... DACF:FT.L.LI.I'•G CIF' At•d'r' S'r'=;TEM WITHCJUT FINAL INSPECTION AND AF''F'F:CI',+AL BY THIS DEPART09ENT WILL BE SUBJECT TO PROSECUTION. MINIMI.IM DISSTANC:E BETWEEN A 14ELL Al, -4D I-Ir'a'r ON S -ITE 'SEWAGE DISPOSAL SYSTEM IS iCKI FEET FOR Fl F'F:ivi:ITE WELL OR T.5%i TO 200 FEET F'F.:IJM A PUBLIC WELL DEPEt•DIt-m l!F'ON THE TYPE OF PUBLIC 14ELL.. MIkIIt'ILIN DI:=",'1TANC:E F."ROl'I Il PRI% -'ATE WELL TO A PF:IVAT'E SEWER LINE IS 25 FEET AND TO A I.:::CI -11,11.0,11 T Y SEWER I .P.1E: IS 75 FEET. !JELL. LO11:`; ARE: REC!I_IIRED E'Ir'D trll_I'.="r BE RETURNED TO THE DEPARTMENT WITHIt.1 . G9 [:AI-i'S DF THE' WELL COMPLETION. ".ITHEF: R'E.OILIIF:Et P-4TS t'IF'IY AF'F'L'•r'. SPECIFICATIONS AND I.rlydE,rF:I_II 1'ICird DIA RAMS" FIRE �T'v'AILABLE TO ItdSI_IF:E PROPER INSTALLATION. 1"=` 1 : 1� 8'• 1 �: "Y . o ." TC I -e E E w- . IES" I— C'- E-.1. 1 EE EE t -e :1. :::8... T. C:ERTIF'',' THAT.. J_: I Arg FAMILIAR hd I TH THF.: REQUIREMENTS FOR ON --SITE :-EWERS AND WELT..:_, A,-::: SET "C'IF:T'H BY THE.' trll. N I I;' I PAL I T''r OF ANCHORAGE _..: I W11. L. IN= T'ALL THE .'r::>"rEh1 14 ACCORDANCE WITH THE CODES. DES. I I_II'dC: EF:::'fFitdCr THAT T"FIE Iar,I '= I "rE SE 14EF: 'SYS -':TEM MAY REQUIRE Er•,ILARGEr'1ENT IF THE IS REr OD'CLEC:, TO INC:L.LIClE 1-10f":E:. THAN 4 EIk:DF:CICIM,_::... HE'E'L I rfTt•d'1" 1"C��Fa. LF, i UOF:_;E 1 H _____._..__../�._ �. �""!__ _L: HT E:..__ t/._......._ __ r' 1. F,t N ° N o_.n N" -,.N .9.. N--' fi. N--' N --N L_ JL -.N-_ ",r" -p II. 0::zl PA U'-"- UA C, F" F -N I'D I•— DE F'AF:T't lENT HEALTH AND ENVI I ROhIMENTA _, •_ ,25 'L STREET: Ar•dI�l-ICIRAGE: Al--:. S15_ ,_L1;a_ 264---4720 1-" J JE._ 1.._ 1._ 11=1 1"- s t..:a 0 VA .7_• I -'r'- e-: 1 u u 4 rE: FP F1E F=:° r• -t I ..t — F'ERI I I T NO. ,=;00_--j''j'1 f-lPf"T. I:C;FINT T'CIF:L,ILF"' H� iFSETH 1552 E,IJ �J SR ANCHORAGE LC"I C III I CIN ( � LE G'AL L4 Bli MT F'FIRK ESTATES LCAT SIZE `:0000 SQUARE-FE."ET "'r'F'E: OF SOIL ABSORPTION '_'r':`;TEh1 11-3: TF:EhIC:F1 t'dI_IMBER OF C,ECPCrtIMS =- d. SOIL. RATING (SQ F=T,'C:,F:).= ':bil=l TF1E PD.71.1IF:ED SIZE OF THE v,MIL A ORF'TICIrd ` YSTErI Is: pN_d ET 1_ " _.t.._ VA == J- Q It— IEE t°-.1 8-3 _1.t..•'t •pct 1 m 9:3 fes:' FA IEE t._. IC:" E=. FK -f- t .g THE L_E"NGTH DIr'IEY.-ISION IS -rHE. LENUaTH CIN FEET) OF THE TRENCH OR DRAINFIEL.D. THE C-Ef'TH CIF' A T'f Er CII CIF: PIT IS THE DID TANC:E BETWEEN THE: SURFACE OF' THE I.ROLINC III'IC: THE BOTTOM OF THE E.,,C:A%A-rION (IN FEET). Tf-ifsRE: I -S NO SET WIDTH FOR TRENCHES. rtlEC GRA',�EL DEPTH IS THE I''1INIr'1UM DEPTH OF GRAVEL. BETWEEN THE OUTFALL. PIPE. 1=II'•11C) THE E,CITT'OI-1 OF 'rFIE E"4`0I=IVATION !:IN FEET::.. F'm U'e N_=@ 1_..N I F1, ICE C. PE F _.t'_ 1 C 9- r-1 VA 1-=': -. 1 W- IES.: J_ 22 W-5; Cs 1:3 F1 N._. M_. a -c P-4 e PERMIT I=1F'F•'L_ i C `A-ff HAS THE F:E.SPCiNS I B I L... I TY TO INFORM THIS DEPARTMENT DURING THE: I NSPEC:T I CIr•d::l CIF t'it•d',•' WE'LL.' ADJACENT AC:ENT TO THIS PROPERTY AND -['HE I.RIrIBER OF RESIDENCES-: THAT THE WELL. WILL. 'SEW'.1E::. _. _.._........... 71..1 NW N d'. LL:11iT PA �-3 IF E: C -r I ND P-A::E F -i F -v R . FZZ C:...: e. -r 9.._1 1 FR C- G'" __. _..... DACF:FT.L.LI.I'•G CIF' At•d'r' S'r'=;TEM WITHCJUT FINAL INSPECTION AND AF''F'F:CI',+AL BY THIS DEPART09ENT WILL BE SUBJECT TO PROSECUTION. MINIMI.IM DISSTANC:E BETWEEN A 14ELL Al, -4D I-Ir'a'r ON S -ITE 'SEWAGE DISPOSAL SYSTEM IS iCKI FEET FOR Fl F'F:ivi:ITE WELL OR T.5%i TO 200 FEET F'F.:IJM A PUBLIC WELL DEPEt•DIt-m l!F'ON THE TYPE OF PUBLIC 14ELL.. MIkIIt'ILIN DI:=",'1TANC:E F."ROl'I Il PRI% -'ATE WELL TO A PF:IVAT'E SEWER LINE IS 25 FEET AND TO A I.:::CI -11,11.0,11 T Y SEWER I .P.1E: IS 75 FEET. !JELL. LO11:`; ARE: REC!I_IIRED E'Ir'D trll_I'.="r BE RETURNED TO THE DEPARTMENT WITHIt.1 . G9 [:AI-i'S DF THE' WELL COMPLETION. ".ITHEF: R'E.OILIIF:Et P-4TS t'IF'IY AF'F'L'•r'. SPECIFICATIONS AND I.rlydE,rF:I_II 1'ICird DIA RAMS" FIRE �T'v'AILABLE TO ItdSI_IF:E PROPER INSTALLATION. 1"=` 1 : 1� 8'• 1 �: "Y . o ." TC I -e E E w- . IES" I— C'- E-.1. 1 EE EE t -e :1. :::8... T. C:ERTIF'',' THAT.. J_: I Arg FAMILIAR hd I TH THF.: REQUIREMENTS FOR ON --SITE :-EWERS AND WELT..:_, A,-::: SET "C'IF:T'H BY THE.' trll. N I I;' I PAL I T''r OF ANCHORAGE _..: I W11. L. IN= T'ALL THE .'r::>"rEh1 14 ACCORDANCE WITH THE CODES. DES. I I_II'dC: EF:::'fFitdCr THAT T"FIE Iar,I '= I "rE SE 14EF: 'SYS -':TEM MAY REQUIRE Er•,ILARGEr'1ENT IF THE IS REr OD'CLEC:, TO INC:L.LIClE 1-10f":E:. THAN 4 EIk:DF:CICIM,_::... HE'E'L I rfTt•d'1" 1"C��Fa. LF, i UOF:_;E 1 H _____._..__../�._ �. �""!__ _L: HT E:..__ t/._......._ __ r' 1. F,t ❑ SOILS LOG MUNICIPALITY OF ANCHORAGE y/ DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION PERCOLATION TEST 825 L. Street, Anchorage, Alaska 99501 264.4720 `— SOILS LOG — PERCOLATION TEST PERFORMED FOR: Ho/=5A� o/=5 A�� DATE PERFORMED: 5 LEGAL DESCRIPTION: 11/ / , P/<—�• DEPTH / (FEET) j j sl l 2 _ f 3 5 c . 6 I� -f—y 7 8 9- 10- 11 - 2 - 13" 14- 15" 16 17 - 18 19 20 COMMENTS •oafs sig+sun+.r°°ea°°t �e NO. 1732-E c t aA Juno 22, 1963 p + ° SITE PLAN MESE' NONE OMEN MENE MEMO MINNM MM■ ■EN■ E■EE ME■E NONE. Ai E WAS GROUND WATER [% S ENCOUNTERED? L O z E P IF YES, AT WHAT E / DEPTH? Reading Date Gross Time Net Time Depth to Water Net Drop Z a Z 7— yi L� �Z> PERCOLATION RATE _(minutes/inch) TEST RUN BETWEEN FT AND `-? FT PERFORMED BY: c�v7.S � `%� CSL �4<-- CE_RTIFIED 72-008 (6/79) DATE: 9 IV() 19ksvllkm lumlilitil(D WZ �; 13OX 13609 STAR, )[?LouwIG A ANCUORAGEv. ALASKA 99502 344-7714 SIX INCH WATER WELL DRILLED AND CASED OUT TO THE DEPTH OF -192 Feet. DRILLED AT THE RATE OF $12,00 0 PER FOOT. PROPERTY OWNER [ft. 7o&kt:t llot4e:th. 344-3578 _ E' LOCATION OF WELL SITE— ° # Blk. & Ste^ /%i�rtt2 DRILLER Been to Clad o� RampaU D&Zi,( in,r, Wo&k4. WELL LOG: 0----77' S.r Lt4 cptave.t. 40°6 cto4. 77----64' San.&j, j i.n,e gAzue.L. 401% clary. 64--737' Ha&dpan.. Cemented gtcave - 137-788' filet c) -cul. 45% fine 9,taveL. 188-7,92' Nat" bea4,tnq . i.n.e grave L. 4cjfC( ptcoduction, wt h 35 Ae,t of wa.ten 4 tand.iruk .in, c_"'ca'. 3/4 HaA4e Su &aetr4-L&ic pomp 4hou.Ld be ia4 atLed 4 feeA ag bottom. Coot of- Dir U-ing.: $3648.00 MUNICIPALITY of DEPT. ANCFjoj,; ;- Coot of- Oeit Se.a.L: $22.50 E-NvIRONivIENTI;,_ nC"f , Lilo„I Rampax t 4uggedt.6 Rnchwtage We.L & Pump .to ttw4aU Sub Pump. 243-0740 COST INCLUDES ALL LABOR AND MATERIAL FOR COMPLETION OF SAID DRILLING. WRITE CHECK PAYABLE TO RAMPART DRILLING WORKS FOR THE SUM OF $3670.50 THANK YOU VERY MUCH. >4�a�lw BERNIE CLAUS OF RAMPART DRILLING WORKS DATE— Sept 14tt 1980 (2� SERVICE CHARGE OF 1%% PER MONTHLL BE ASSESSED ON PAST DUE ACCOUNTS. w r MUNICIPALITY OF ANCHORAGE + t)f_PArl rmENT OF HEALTH AND ENVIRONMENTAL PNOYECTION DIVISION Of ENVIRONMENTAL VICALTII CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL. OF ON-SITE= SEWER AND WATER FACILITY 264-4720 Application Date - 1 -3 -CUSS ------------ i. c:, L. P,9r�:r3A1. iNF0NPils`1'! i0N (a) I-egal Description (include lot, block, subdivision, section, township, range) Location (address or directions) (t;) Applicant Name _ TaritJ_L 17o:E4 L i_-Co'i pLio oHome _3_63 03A4— Business .--Mme--_--- Aoplicant Address �2C..1�1_pin�_Ilr_ivB�—Anc]�pxagAl�9�.�1 6-- ---.-..-------.___- (c) Applicant is (chock one): Lending Institution D , Owner/builder fRa ; Buyer L7 , Other 0 (explain); (() Lending Institution - _-_-- -- Telephone Address — - - - - — — (e) Real Estate Cornpany and Agent — -. - -- - —-------- -- ---- --- Address-- -Telephone -- ----_---- -- (f) Miail the HAA to the following address: Tourlf Hofseth Cons tiu-c-tion--- Go. _ __- 12431 Alpine Drive Ancho"-a; e AK 90516= 7:21 2. TYPE OF RESIDENCE Single -Family F Multi -Family lel Other Number of Dedroorns Zl._ ___ __ 3. WATER SUPPLY Individual Well Fq Community 17 Public 0 Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 4. SMAGE DISPOSAL Onsite Ux Public I-] Community ❑ Holding Tank Ll Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 72-L25 01,£34) Page 1 of 2 5. /ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, OAYA AND INFORMATION a G. As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Heaalth Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated 'herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Name of Firm / ` -- —==- Telephone- -- - Address - - - - -- - - ---- -- Date DHEP AKNIOVAL Approved for 6W - _.. bedrooms by�� ' --_ Date Approved Disapproved --__-__--_ Condr�rrrtCCloonal . — Terms of Conditional Approval CAUTION The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority Approval certificates based solely upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHEP does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and stale requirements. Employees of DHEP do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is riot responsible for errors or omissions in the professional engineer's work. I Page 2 of 2 UtYI. Ur ]ICHLI rl & ENVIRONMENTAL PROTECTION MUNICIPALITY OF ANCHORAGE ( MOA) Dor" 'j Li '1985' HEALTH AUTHORITY APPROVAL (HAA) RECEIVED �, `j CHECKLIST - FEBRUARY 1984 R E C E1 if E D Legal Description A. WELL DATA � LL�� L Well Classification `l �" 7 If A, B, or C, D.E.C. Approve(i(Y/N) _ Well Log Present (Y/N) Date Completed � - 9�) .' 'Yield Total Depth /`% 7 ' Cased to 0V f __ Depth of Grouting Ly A Static Water Level / ` Pump Set At Casing Height Above Ground ?I Sanitary Seal on Casing (Y N Electrical Wiring in Conduit (Y/N) Depression Around Abllhead (Y/N) �� Separation Distances from Well: 1 ' J �j� �� on Adjoining Lots To Septic/Holding Tank on Lot //-i �o s ,� ._� To Nearest Edge of: Absorption Field on Lot/ /cam '�'• On Adjoining Lots f /G To Nearest Public Sewer Line A�1111 To Nearest Public Sewer i Cleancut/Manhole / /tel _ To Nearest Sewer Service Line on Lot SO Water Sample Collected ByC �y 1 S (-�� j �r Ste; skate /U%S Water Sample Test Results Comments B. SEPTIC/HOLDING TANK DATA Date Installed _! S �� ' Size / No. of Compartments z Standpipes (YM) Air -tight Caps (Y ) Foundation Cleanout (Y/N)r�-- Depression over Tank (Y/N) !v Date Last Pumped 4Jlf Pumping/Maintenance Contract on File (Y/N)!0 for Holding Tank High -Water Alarm (Y/N) til - Temporary Holding Tank Permit (Y/N) ti Separation Distances from Septic/Holding Tank: To Water -Supply Wall //�' Lv s '.)� _, To Building Foundation /L To Property Lire / /U To Disposal Field / Y' _ To Water Main/Service Line To Stream, Pond, Lake, cc Major Drainage Course ✓ -)'Ij Comments ' d (,U Vi /'_5 S"i %i"L= �1-::�'i' T/f%7/�� ,� �� C=wi f ff.S L,S Receipt # a '5 37_�_ Date Paid: IO •• I Amount: LIS (Page 1 of 21 2-15-84 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata 00 Type of System Design Date Installed Length of Field Width of Field Depth of Field Gravel Bed Thickness �11 J Square Feet of Absorption Area �`��' ' Standpipes Present (YIN) Y Depression over Field (YM) Date of Last Adequacy Test A, Results of Last Adequacy Test Separation Distance from Absorption Field: To Water -Supply Well f / O 1� To Property Line To Building Foundation -A To Existing or Abandoned System of Lot AL' /I ; On Adjoining Lots � "� o To Water Main/Service Line -/ -5 o / To Cutbank(if present) To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Comments ��c �•1 el --f � �� ro ;,� ,-� � //!, Y� 1!5 %' ;> ,, � �• S .. Ju S� `< �>, /�' D. LIFT STATION — 1-/4 Date Installed Dimensions Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes(Y/N) Comments Manhole/Access (YIN) "Pump Off" Level at Vent (Y/N) Pumping Cycles during Adequacy Test. Meets MOA ** Check Permitted Bedroom Rating Against HAA Request ** I certify that I have checked, verified, or conformd to all MOA ESA Guidelire�,."in'etre on the date of this inspection. /� Signed Date L�i Company MOA No. KBl/d5/s : (Page 2 of 21 r_ 2-15-84 Ourulf Mvfset4 Tuustructtnn (go, 12431 Alpine Drive October 1, 1985 TO WHOM IT MAY CONCERN: Anchorage, Alaska 99516-3121 (907) 345-0844 The septic system at Lot 4 Bloc1,� 11, Mountain Park Estates has not been used until recently. Sincerely, i�-(�;;GI E,/r✓CLQ=%/J 2sa{`,' G L TORULF HOFSETH General Contractor T- PI C-_ l/1 [ o' AA'/ t l r� NORTHERN TESTING LABORATORIES, INC. 600 UNIVERSITY PLAZA WEST, SUITE A FAIRBANKS, ALASKA 99701 907-479-3115 6957 OLD SEWARD HIGHWAY, SUITE 101 ANCHORAGE, ALASKA 99502 909-349.8623 Drinking Water Analysis Report for Total Coliform Bacteria TO BE COMPLETED BY CLIENT ❑ PUBLIC WATER SYSTEM I.D. #E1 \[ PRIVATE WATER SYSTEM L q�/ j f.+V� � P 4 t G - S T; `_OV,1L54-' • \(a ✓15 r 3 L—v)c— // 9 r J NAME / G. fes. l✓ p Mailing Address city State (� SAMPLE DATE: / � Phone Mo. Day Year Purchase Order No. SAMPLE TYPE: Routine ❑ Special Purpose ❑ Check Sample (for original contaminated sample with lab reference no. -- Sample ,tf No. Location 1_// 2 3 4 5 6 7 S 9 Time Collected Zip Code ❑ Treated Water 4 Untreated Water Collected by Laboratory Ref. No. 11 0<S2,0 10 - Signature of Representativ FOR LABORATORY USE ONLY CASH CHAflGE PgEPAID UNSATISFACTORY SPECIAL IN57flUCTIONS MAIL R xxtD EDfl OB TOO NUMEROUS TNTC TTPANSMITTAL PICKUP .. u.. .._GCI- ". TO BE COMPLETED BY LABORATORY Received at: [2 Anch. ❑ Fbks. Date Received 'L Time Received Next Sample Due COMMENTS: SATISFACTORY UNSATISFACTORY U RESAMPLE R OTHER BACTERIA OB TOO NUMEROUS TNTC TO COUNT Direct Verification Pinel Count LSB 13GR Result- Comments fro. of Tot CHI or lonies per 100 m1:>. ported by - Date