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HomeMy WebLinkAboutALYESKA Block 11 Lot 22 · i ! ~):;i!?ll.I ~:,[.ri :, ].': i: IN (- II 'Al IIY ( )1: ANCI I(-)RA(:~I! I)FI¥1. ()F l' All'il & :NVII,X)NIv~I I' ' ! ~ ( i IQF-~ q'( ) I (:1 t%' 't)B/1 I~, Date DEFARTMENT OFH~ALTH AND SOCIAL 'RVICES DIVISION OF PUBLIC HEALTH Lab. No. BACTERIOLOGICALi;WATER ANALYSIS PLEASE MAIL RESULTS TO: NAME ~-'~-'~ "(~' \:~ ¢~/'~ '~ '~ ~' ADDRESS: ~ ..... ~ .... ~,~ ~ ..., CITY_ ~ -~ ........ ~ /' ~k ~- ZIP CODE S~ple collected by '%~>, ~ Phone No.-~: -- Date Collected ': ~.--' ~_ ~, ~ ~'~ Time - .~. .- ~ ~. ~ Specific place of collection ~.~_ .~_.~_'~' :~ .;( :'~ '~'~?q~.~-3 REASON FOR SAMPLE SUBMISSION: [] Illness suspected- [] Health Regulated F~tablishment [] Other WATER SAMPLE SOURCE - ~]"Well Type of casing [] Improved (Enclosed, Cover~) Spring [] Surface (ReserVoir, ~,trearn, lake~_ [] Hold,rig Tank ~-) [] Other' <~ Office .... A~nalysis shows this. WATER SAMPLE to be: ~Satisfactory - ' [] Unsatisfactory [] Questionable [] submit other sample [] Sample too long in transit to indicate reliable results. Sample should not be over 48 hours old at time of examination. [] Bottle broken or ieaked in transit. [] Other SANITARIAN'S REMARKS '-,'Sanitarian's Signature: READ INSTRUCTIONS BEFORE COLLECTING SAMPLE / 06-~220 (0) BACTERIOLOGICAL WATER ANALYSIS RECORD Rev, 1978 Date Collected Source· Date Received- ' ~ ' Time Recelvecl ~_.~.~m~ _Lab. No. .Pres.9 mot Ive ~, 10mi 10mi 10mi 10mi 10mi 1.0mi 0.1mi 24 Hours~l .v-; 48 Hours Confirmatory 24 Hours 48 Hours -. EMB_ ~ultlple Tube Report:,~:~ ~" Broth 24 hours:, Broth 48 hours: 10mi Tubes Positive/Total 10mi Portions ~embrane Filter: Direct Ce~nt. Coliform/100ml ;ZVerlflcatlon: LTB BGB' , F~lnal Membrane FIl~et?esults -. , Collform/100ml Reportec~ By -- , Date, ~ ' Time: p.m.