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vo+c�r�V�� ��.�+'� IrRJS) F'.VlI IJWL <br /> DRINKING WATER MICROBIAL SAMPi.E COLLECTION '------------------------------�`------------------------' <br /> 8 LABORATORY REPORTING FORMAT ' 4yri�e project#or PleCe ProJect Label Here <br /> O 68018outl�polnt Pkwy.•.�sdcwnvYl�,F�33216•004.989.A850•Fax 904.968A354•Ea937i : ; <br /> ❑ea�a sw kenw a�d•CiaY�vlNe,Fl 82EOE•362377Z349•Fau 362.305.�639•dZ001 � ; <br /> 10ROD USA Tod9y Nhy•NN�rtir.FL 33025•954.809.�8•F�ot 954.8892261•p:3�S <br /> 9610 Prkoss R�Im Aw.•7ampa,FL 3381@•413.al0.9818•Feic 813.830.1947•El4St9 � ; <br /> 5�28 8.NaM i�trq BNd.,Sta.1Q1�•AM�rwnfs Sprkps.FL 32701•407.937.iS9i•E�.7076 <br /> Ad�ance� ��R��Oab 6 Tims: � QT� <br /> �nsye�s o.a a nm.: •`�./ <br /> E��iro�me�tal baboratories, I�c. �a:�.�,�n p�pn les �3.� <br /> rn.,�cn.d�:CJ.uoNnewc�d �I-� <br /> rr Thls SMnpN tlOSS rtol maet lhe foNowlnp NELAC rsquirsnMnls: <br /> Reporl Number: 1 Sub-Contract Leb ID: <br /> AnN�rsis Rpw�t�d:(chedc a!I that apply) <br /> �Total CdifomdF coli C7Tatel CdMamlFecal ❑Enior0000d ❑Ccliphape ❑HPC (]Other. <br /> Pubfic Water S�rsbm(PWS}Name: ' ��Q��'S PYYS Ld. �Q����� <br /> PWSAddress:�J_ �� � Cily: f'�afi'�y��SL�� <br /> PWS or PWS Ownera Phona�: � � Fex!!:CJ,,� <br /> Coll�dor:�t'3dAlA��l.�.r Collectors Phone� 7I�"'�' <br /> of Suppnr:{chack.only one) <br /> mmtnlly Water System ❑Non-Transbnt Non-commu ' Walar System OTranaient Non-eommunity Water System <br /> imitad Use SystBrn ❑BotUed Water ❑Private Well �s,�►rn�e Poa ❑Other: <br /> R��son tor 8�nP�InO:(check alf that ePP�y} <br /> ❑Disinbullon RouW�e ❑DlsMbution Repeat ❑Raw(tdgpered or aesesement) ❑Raw(triBDerod ot essessmsnt)ad�tional •OWeli Survey <br /> �L:learenoe ❑Re�lacema (al chsck type of sample beiog repiaced) ❑Bdl Water Notloa ❑Other: <br /> 8ampls CoIlsNon Q�t�; ' 3`Z ocwt�aoa5 Ei��e a��s,re.M..d osa��o <br /> S�mpla ' �i�- MdyNs AANhod(i)� A1 <br /> �3°�pl° S��ple Pok�t Cdia�fon S��;° � `�V <br /> i� (Lecatlon or Spseific Addrasa) TYne T1� Rs�ldusl � Noo- Tolal Faeal�E.aof� Oale L�b <br /> • (�^D��) Corform Callform E�'a°� Ouapllsr' ��s <br /> '�5,� 'kSr. ��-� � ,r,� O.� OU l <br /> AvM�of �CLLnt nsldusls for dlsl�utlon reuttn��nput <br /> +ampla.` Frae ns orTolal dibrine dr�N one}. •� • Unfeas o7herwlss nolad,all iests are preformad In aocordance wtth <br /> Ois ohobnt RwduM Mdyal■MNt�od: AIELAC standerds,snd Ihe roeuils rolsl�ony to the samplas. <br /> ������ ❑�r Dsle and Iims pWS no1111ed by faD of podUva fe6ulEs: <br /> !+9 A �op��(#��.1�7��Iwck one of b�low}: Rste and lhie DEPlDOH notllled by kb of pa�lUw rssuila: " <br /> ❑Sup�nA�ed Oak R�poA Iswsd: <br /> by certlfled operalor(� ) <br /> ❑Employed by e seAlllad tab ❑Employed by DEP or DOH Lsb Slynstun• <br /> ❑AuUlOfii�d ropresaMaliv�d suppMer ofVVtllr Tltle' <br /> [L�ISERT NAM�AND MAIIJNti A DDRES,4 AF PERSdN'I'(1 RPCfs'iV E RBMn,tTj DEPIOpH USE ONLY <br /> ❑Sslbtadory <br /> �TY � �ph! E�1�.5 a�.�o������.� <br /> � D R�psat Srnplss R�qulnd <br /> ❑Rapbc�w►t SsmpNs Required <br /> 5��S����"�• oace Rer+o�a ey o�looH: <br /> �-P � r�z�.c.s , ��,� 5'-�1� �,�H����: <br /> .�w...hrg�.r�..d�.�.i.�r..+..�nr..oa....:c.o„rr„r,�wn.mqP+e► Relinquish 8Y� Date��T'�Time: <br /> ��w+ti�.e�w`.�N•E�Nfer:!OMYMMa�.P-awrTw.a.so.argi+�„v,ro.1 <br /> �ns�qwir.ou�aaEawtuawwc�rio.a�wa;��c+ewaue Recalved BY� � Defe: ? TIme:S��'t'�'� <br />