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COMMONWEALTH OF VIRGINIA <br />W &N 11 p FAIRFAX COUNTY HEALTH DEPARTMENT LABORATORY <br />REPORT ON BACTERIOLOGICAL EXAMINATION OF WATER <br />= TIME COLLECTED SPACE BELOW FOR LABORATORY USE ONLY <br />J DATE COLLECTED - �— ��`COUNTY 1 <br />� 11 <br />N <br />O SUPPLY OWNED BY <br />DATE RECEIVED <br />DATE <br />SAMPLE NUMBER <br />1COMPLETED <br />MEMBRANE FILTER <br />= LOCATION C <br />11 <br />MEMBRANE FILTER <br />SAMPLING POINT V ._ <br />e �� <br />�1 <br />Z` C <br />❑ <br />Membrane Filter Coliforms /100 ml <br />Z SAMPLE COLLECTED BY <br />w❑ <br />tr <br />Membrane Filter Fecal Coliforms /100 ml <br /><C IS SUPPLY CHLORINATED? <br />El YES [aNO <br />w <br />Total Bacteria Count TNTC <br />OZ CHLORINE TEST MADE AT <br />SAMPLING POINT? <br />❑ YES NO <br />❑ With ❑ Without Coliforms Membrane Unsatisfactory for <br />Membrane Filter. <br />U <br />RES. CL. <br />PPM <br />N <br />Confluent Growth Please Resample. <br />❑ With ❑ Without Coliforms <br />Lr7 <br />H <br />Q REPORT <br />RESULTS TO: <br />(Y <br />MPN <br />L <br />MPN � �— Coliforms /100 m i #Tubes , <br />W <br />J <br />_ <br />(�� <br />0 <br />MPN <br />Fecal Coliforms /100 ml <br />Q` <br />❑ <br />Dilution MPN Coliforms /100 ml <br />ZZC <br />❑ <br />Dilution MPN <br />Decal Coliforms/100 ml <br />RESULTS BASED ON CONFIRMED TESTS` <br />UNLESS OTHERWISE <br />SPECIFIED <br />