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COMMONWEALTH OF VIRGINIA <br /> FAIRFAX COUNTY HEALTH DEPARTMENT LABORATORY 44' <br /> W REPORT ON BACTERIOLOGICAL EXAMINATION OF WATER <br /> I- <br /> SPACE BELOW FOR LABORATORY USE ONLY <br /> TIME COLLECTED CITY OR II DATE RECEIVED DATE COMPLETED SAMPLE NUMBER <br /> J DATE COLLECTED <br /> COUNTY <br /> � WB <br /> N SUPPLY OWNED BY '�; <br /> CD MEMBRANE FILTER <br /> LOCATION ' }' f ❑ <br /> _ Membrane Filter Cohforms /100 ml <br /> ~ SAMPLING POINT p <br /> C/) ,� W❑ Membrane Filler Fecal Cohforms /100 ml <br /> Z SAMPLE COLLECTED BY <br /> t to Total Bacteria Count TNTC <br /> ~ IS SUPPLY CHLORINATED ❑ YES ❑ NO ' W Unsatisfactory for <br /> Q <br /> F-- p ❑ With ❑ Without Col forms <br /> CHLORINE TEST MADE AT SAMPLING POINT? Membrane Filter <br /> LJ YES ❑ NO H Confluent Growth Please Resample. <br /> U RES CL PPM W ❑ With ❑ Without Cohforms <br /> Q REPORT RESULTS TO U MPN <br /> LLJ MPN Cohforms 100 ml #Tubes <br /> W ' <br /> J / I V ❑ MPN Fecal Cohforms /100 ml <br /> Q— C <br /> ❑� Dilution MPN Cohforms'100 ml <br /> Cn ' k -t / 1 ❑ Dilution MPN Fecal Cohforms/ 100 ml <br /> RESULTS BASED ON CONFIRMED TESTS <br /> UNLESS OTHERWISE SPECIFIED <br />