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COMMONWEALTH OF VIRGINIA <br />FAIRFAX COUNTY HEALTH DEPARTMENT LABORATORY <br />W <br />SAMPLING POINT <br />REPORT ON BACTERIOLOGICAL EXAMINATION OF WATER <br />0Oli <br />V) <br />Z <br />•- <br />SAMPLE COLLECTED BY <br />Q YES <br />Q <br />F¢— <br />IS SUPPLY CHLORINATED? NO <br />SPACE BELOW FOR LABORATORY USE ONLY <br />a <br />TIME COLLECTED <br />Z <br />CITY OR I <br />UV I iUU <br />U <br />DATE RECEIVED <br />DATE COMPLETED SAMPLE NUMBER <br />J <br />DATE COLLECTED <br />REPORT RESULTS TO: <br />COUNTY <br />Y <br />wQ <br />crl <br />WB <br />I �, <br />N <br />SUPPLY OWNED BY <br />G r l <br />(x� <br />CL <br />3;7- <br />= <br />LOCATION � �. � <br />—1 <br />aYl (D-� 1 <br />`1 <br />1 ��YI (I� j "1UU5 °. d+ <br />MEMBRANE FILTER <br />C-111,41 l l <br />! <br />Membrane Filter Cohforms /100 ml <br />~ <br />SAMPLING POINT <br />0Oli <br />V) <br />Z <br />•- <br />SAMPLE COLLECTED BY <br />Q YES <br />w <br />cc <br />to <br />w <br />F¢— <br />IS SUPPLY CHLORINATED? NO <br />Z <br />O <br />CHLORINE TEST MADE AT SAMPLING POINT? <br />❑ YES ❑ NO <br />H <br />U <br />RES CL PPM <br />w <br />H <br />CD <br />Q <br />REPORT RESULTS TO: <br />Y <br />wQ <br />crl <br />W <br />(x� <br />CL <br />3;7- <br />El <br /><r- <br />V) <br />h V <br />of <br />C-111,41 l l <br />! <br />Membrane Filter Fecal Col forms /100 ml <br />Total Bacteria Count TNTC <br />Q <br />With Q Without Cohforms Unsatisfactory for <br />Membrane Filter <br />Confluent Growth Please Resample. <br />QWith Without Cohforms <br />MPN <br />MPN --/ Ot Colilorms- 100 ml #Tubes <br />MPN Fecal Cohforms / 100 ml <br />Dilution MPN Cohforms 100 ml <br />Dilution MPN Fecal Cohforms -'100 ml <br />RESULTS BASED ON CONFIRMED TESTS <br />UNLESS OTHERWISE SPECIFIED <br />