19825 80TH AVE W.PDF111111111111
7104
19825 80TH AVE W
M E M 0 R A N D U M
March 4, 1993
V1
TO: John Bissell
Code Enforcement Technician
FROM: Ron Holland �L �
Water/Sewer Supervisor
SUBJECT: 19825 80th Avenue West Illegal Pool Drain to Storm Sewer
On March,3, 1993; City crews notified my office that a resident living
at the above address was discharging pool to storm drain open ditch.
City personnel notified the owner that this was not the correct way.to
discharge of pool water and that it should be discharged to sanitary
sewers.
I feel that you should be made aware 'of this for future enforcement and
to possibly require the homeowner to tie into sanitary sewers per City
requirements. If this is not required, please notify my office for my
own future enforcement actions.
cc: Address File V/
POOLDRN/TXTSEWER
NOTICE:
No warranty of accuracy.
The information'shown on the attached
map(s) was compiled for use by the City of
Edmonds, its Employees and Consultants.
The City of 'Edmonds does not warrant the
accuracy of anything set forth on these
map(s'). Any person or entity -req uesting a
copy should conduct an independent
inquiry regarding the information shown on
tFe -map(s), including, but not limited to,
the location of any sewer stub shown. Such
sewer stubs may or may* not exist and may
or may not exist at the location shown.
Neither the City of Edmonds nor its
employees or officerS.) shall be liable for the
information given on this map(s), nor for
any one representation provided based
upon said map(s).
WHEET FILE
The City of Edmonds
APPLICATION
for
SIDE SEVEM PERMIT PLANr BASEMENT No.
NEW CONSTRUCTION 0 REPAIRS C]
OWNER ............ ........................
CONTRACTOR ........... ........ 7X ........................................ PERMIT No.
ADDRESS .... . .... --- — ----
........
LEGAL DESCRIPTION: LOT No - ------- e-2. Zo ................
........ BLOCK No. . ...........................................
NAM ADDITION .......
. . ............. ...... ............... ..................
7T
Ae4-
14
q -7
APPROVED
AUG 11967
ero � I
Approved:
DATE ... g - . 0
:7�-/ .. 4-2 ................ ] . .
!� Y .....
� !!!7
CITY10 F EDMONDS
CIVIC -CENTER — WATER -SEWER DEPARTMENT
.'SIDE SEWER PERMIT
C - all PR*spect:.6-1107 when.. work
is ready for Inspection. .(No inspee-
tions Saturdaoy, Sunday or holidays.) 2411
19825 - 80th Ave. W.
ADDRESS.................. . . . ............................................................................................................................................................................
OWNER ........ Andre:w ... Glick ............................................ ........ CONTRACTOR ....... 1�qy ... 419�p .................................................
rerniission Is granted J.0 ly .... U ................... 1 19�7_ for ........................ days 'to REPAI . It or CONNECT a side sewer
- with City Sewers in accordance with application on file.and governing ordinances.
ATTENTION IS CALLED TO THE FOLLOWING:
NOTE No. I —The owners of the property may obtain a permit to construct sewer inside property line. A licensed Side Sewer Contractor must
be employed to construct side sewer In street area. Do not cover any portion of sewer before It has been Inspected.
NOTE No. 2—Obtain full information regarding Ordinance 11.16.030 and Regulations governing side sewers when you get permit.
NOTE No: 3—Top of side sewer must have at least 30 Inches coverage at property line and 12 inches Inside property line; minimum grade of 2%.
No bonds In grade sharper than % will be permitted.
NOTE No. 4—Trenches in street must be water settled and surface of street restored to original condition. Contractors shall be responsible for
failure due to improper work which may develop within one year of completion.
N�__. No. 5--It is unlawful to alter or do any other work than is provided for In the permit, or to do any work on the main sewer or its appur
tenances except to insert the pipe into the wye.
STAT13OF WASHINGTON
IDEPARTMENT OF SOCIAL AND HEALTH SERVICES.,
WATER BACTERIOLOGICAL ANA'LV"SIS
SAMPLE COLLECTION: READ INSTRUCTIONS ON BACK OF GOLDENROD COPY
If instructions are not followed, sample will be rejected.
DATE COLLECTED TIME COLLECTED I COUNTY NAME
MONT/ DAY /'�EAR
a
AM PM1 "
TYPE OF SYSTEM IF PUBLIC SYSTEM, COMPLETE:
PUBLIC I.D. No.
El INDIVIDUAL
(serves only 1 residenc I
CIRCLE CLASS
1 2 3 4
NAME OF SYSTEM
SPECIFIC LOCATION WHERE SAMPLE COLLECTED SYSfEM OWNER/MGR. NAME & TELEPHONE No.
(le, kitchen tap @ school, fire station, fountain)
I L L-A �L
SAMPLE COLLECTED BY: (Nam�)
/'A'
SOURCETYPE
COMBINATION
SURFACE WELL SPRING PURCHASED or OTHER
SEND REPORT TO: (Print Full Name, Address and Zip Code)
WASHINGTON
TYPE OF SAMPLE
(Che.qk only one in this column)
1 DRINKINGWATER Chlorinated (Residuak/' _'TotaI62 —,—/Free)
check treatment Filtered
El untreated or Other
2. El RAW SOURCE WATER "13;'
3. El NEW CONSTRUCTION or REPAIRS
4. El OTHER (Specify) //-. 7
COMPLETE IF THIS SAMPLE IS A CHECK SAMPLE
$REVIOUS LAB NO.
PREVIOUS SAMPLE COLLECTION DATE
REMARKS:
LABORATORY RESULTS (FOR LAB USE ONLY)
MPN-COLIFORM STD PLATE COUNT SAMPLE NOT TESTED
BECAUSE:
_/5 tubes positive /ml
MPN DILUTION TEST UNSUITA9LE Sample Too Old
100 ml 1 Confluent Growth Not In Proper Container
MF COLIFORM 2. F-1 TNTC Insufficient Information
1,00 ml Provided —Please Read
El Excess D b— Instructions on Form
3 . ris
FECAL COLIFORM
El MPN D MF
_/ ; o mi
`0 ml
4. [1
FOR D 5, NKING WATER SAMPLES ONLY, THESE RESULTS ARE:
ED SATISFACTORY El UNSATISFACTORY
SEE REVERSE SIDE OF GREEN COPY FOR EXPLANATION OF RESULTS
LAB NO. A! DATE, TIME RECEIVED— RECEIVED BY
lo
DAT P
QRTEQ.,__ LAIIIATORY,',O�,
REMAAKS
STAT60F WASHINGTON
WAWEPARTMENT OF SOCIAL AND HEALTH SERVICES
R BACTE R10'5L"4`6G I CAL ANA'LAIS
SAMPLE COLLECTION: READ INSTRUCTIONS ON BACK OF GOLDENROD COPY
If instructions are not followed, sample will be rejected,
DATE COLLECTED TIME COLLE-55 NAME
MONTH DAY YEAR COUNTY
YAM
PM[
TYPE OF SYSTEM
PUBLIC
El INDIVIDUAL
(serves only I residence)
IF PUBLIC SYSTEM. COMPIL
I.D. No.
111011
CIRCLE CLASS
2 3 4
NAME OF SYSTEM
J,
SPECIFIC LOCATION WHERE SAMPLE COLLECTED SYSTEM OWNER/ MGR. NAME& TELEPHONE NO.
Ile. kitchen tap @ school, fire station, fountain)
SAMPLE COLLECTED BY: (Name)
SOURCETYPE
El SURFACE 1:1 WELL 1:1 SPRING PURCHASED El COMBINATION
4 orOTHER
SEND REPORT TO: (Print Full Name, Address and Zip Code)
_WASHINGTON.o
TYPE OF SAMPLE
(Che�,'k only one In this column)
41
1. DRINKINGWATER Chlorinated (Residua(�' Totalt��LFree)
check treatment Filtered
El untreated or Other
2. RAW SOURCE WATER
3. El NEW CONSTRUCTION or REPAIRS
4. El OTHER (Specify)
COMPLETE IF THIS SAMPLE IS A CHECK SAMPLE
RREVIOUS LAB NO.
PREVIOUS SAMPLE COLLECTION DATE
REMARKS:
LABORATORY RESULTS (FOR LAB USE ONLY)
MPN - COLIFORM STD PLATE COUNT SAMPLE NOT TESTED
BECAUSE:
_/5 tubes positive /ml
MPN DILUTION TEST UNSUITA93LE El Sample Too Old
/ 100 rnI 1. D Confluent Growth El Not in Proper Container
MF COLIFORM
2. [:1 TNTC El Insufficient Information
100 ml Provided —Please Read
3 171 Excess Debris Instructions on Form
FECAL COLIFORM
El MPN El MF
/100 ml
4. 171
ME]
FOR PDNKING WATER SAMPLES ONLY, THESE RESULTS ARE:
S,
SATISFACTORY UNSATISFACTORY
SEE REVERSE SIDE OF GREEN COPY FOR EXPLANATION OF RESULTS
CIRCLE CLASS
2 3 4
NAME OF SYSTEM
J,
SPECIFIC LOCATION WHERE SAMPLE COLLECTED SYSTEM OWNER/ MGR. NAME& TELEPHONE NO.
Ile. kitchen tap @ school, fire station, fountain)
SAMPLE COLLECTED BY: (Name)
SOURCETYPE
El SURFACE 1:1 WELL 1:1 SPRING PURCHASED El COMBINATION
4 orOTHER
SEND REPORT TO: (Print Full Name, Address and Zip Code)
_WASHINGTON.o
TYPE OF SAMPLE
(Che�,'k only one In this column)
41
1. DRINKINGWATER Chlorinated (Residua(�' Totalt��LFree)
check treatment Filtered
El untreated or Other
2. RAW SOURCE WATER
3. El NEW CONSTRUCTION or REPAIRS
4. El OTHER (Specify)
COMPLETE IF THIS SAMPLE IS A CHECK SAMPLE
RREVIOUS LAB NO.
PREVIOUS SAMPLE COLLECTION DATE
REMARKS:
LABORATORY RESULTS (FOR LAB USE ONLY)
MPN - COLIFORM STD PLATE COUNT SAMPLE NOT TESTED
BECAUSE:
_/5 tubes positive /ml
MPN DILUTION TEST UNSUITA93LE El Sample Too Old
/ 100 rnI 1. D Confluent Growth El Not in Proper Container
MF COLIFORM
2. [:1 TNTC El Insufficient Information
100 ml Provided —Please Read
3 171 Excess Debris Instructions on Form
FECAL COLIFORM
El MPN El MF
/100 ml
4. 171
ME]
FOR PDNKING WATER SAMPLES ONLY, THESE RESULTS ARE:
S,
SATISFACTORY UNSATISFACTORY
SEE REVERSE SIDE OF GREEN COPY FOR EXPLANATION OF RESULTS
LAB NO.
DATE, TIME RECEIVED—
RECEIVED BY
- y IYA 11
' Va�f
DATE REPX,,D
LA136RATORY:
'REMARd
Stle of Washington
Department of Social and Health Services
Health &Kvij:es%Di4.on B17-9
Smith Tower, Seattle, Washington 98104
WATER, BACTERIOLOGICAL ANALYSIS
READ. INSTRUCTIONS ON BACK OF GOLDENROD COPY
IF INSTRUCTIONS ARE NOT PROPERLY FOLLOWED,
SAMPLE WILL BE REJECTED.
FOR LAB USE ONLY CO.-CITY'-(e-ioi�,, III . 141
LAB. NO. (1 -71
1150 a/10 `�;/O
DATECOLLECTED 65-2co DATE STARTED, ;.Ii7l� (28,1310),
M L
onth Day Y i2 I
TIME OF DAY Met I;D - NO,.0pubJW Systems) COUNTY NAME
C3
CO,LLECTED AM'I 311 (32 (33) ['13 1 4) M 5)
-6, 0 PM 2
NAME OF WATER SYSTEM CIRCLE CLASS
1 2 3 4
SYSTEM ADDRESS
LOCATION WHER� SAMPLE WAS COLLECTED (fire 3ioa-flon, school,'Sth
COLLECTED BY: (Name)
TYPE OF 136) 1 (DMunicipal or 2 o Industrial P 1vole
cSYSTEM Community Commercial or 3 0 Residence
SEND REPORT TO: (Print Full Nome, Address and Zip Code)
WASHINGTON-,/,
SOURCE TYPE t37) Combination
1 0 Surface; 2 0 Well; ;,� 0 Spring; 4,0 Purchased; 0 or Other
TYPE OF SAMPLE (381 (CHECK ONE ONLY' New Swimming- Swimming
I '(D" Drinking - Water 20Row 30'Moin�401`ool ; '_ 5 d Beach
! \ Sanitary I I �� I Water Shellfish - q 0 OtherfyJ
6 0 Survey 7 0) Seawater' 80 Study' (Speci
IS THIS SAMPLE A FOLLOW-UP TO A (391
PREVIOUS, NON -CONFORMING SAMPLE? 10 Yes 0 (;)"No
IF YES, GIVE PREVIOUS LAB. NO.
,691 SYSTEM TREATMENT (Check only for Drinking Water Samples)
1 0 None; 2 Chlorination; 3 0 Filtration; 4 0 Fluoridation;
9 0 Other (Specify)
REMARKS:
LABORATORY RESULTS
SEE REVERSE SIDE OF PINK COPY FOR INTERPRETATIONS
A. COLIFORMS PER 1 00ml C. FECAL COLIFORM [I RESUBMIT SAMPLE
5 TUBE MPN TEST 440) MPN /looml Test Unsuitable Because:
1. F] - 0/5 =<2.2 170) 1. 0 Can it Vent. Growth
2. El- 1/5 = 2.2 (57-60) - E - , 2. 0 TNTC
3. F1 - 2/5 = 5.1 MF /looml 3. 0 Excess Debris
(61-64) - E - 4
4.[:)- 3/5 = 9.2, 0 RESUBMIT SAMPLE 111-7.)
5� 0- 4/5 = 16 Sample Rejected Because: (Check One I Or More)
6. 5/5 = �16 1. Sam -pie Too Old
MF 0 /loom] E3 Fee Not Provided
(41-441
1� E �_T 3. El Somple Received Too Late In Week
MPN DILN. TESTS Insufficient Information Provided.
/100 ml Please Read Instructions On Form.
45-4#- 0 - E - 5, O,tqot In Proper Container
B. STD. PLATE COUNT 6. C3 Leaked Out
7. El Other (Specify)
/ml
sfbe of wasAngton
Department of Social and 'Health Services
Health Services QJ yjman B 17-9
Smith Towe0%;;rtl7W1hington 98104
WATE.R.,;BACTERIOLOGICAL. ANALYSIS
READ INSTRUCTIONS ON BACK OF GOLDENROD COPY
IF INSTRUCTIONS ARE NOT PROPERLY FOLLOWED,
SAMPLE WILL BE REJECTED.
FOR LAB USE ONLY, CO. -CITY- is-io),
LAB. N
DATE1.0VECTED 05-2o) DATE STARTED (27�
Mon,/ Day Year f2I.2rI`
TIME OF DAY '68'- NO. (Public Ststems) I -COUNTY NAME
COLLECTED . EfAM 1321 13:3) (34) 135,
PM,�
NAME OF WATER SYSTEM CIRCLE CLASS
1 2 3 4
SYSTEM ADDRESS.
LOCATION WHERE SAMPLE WAS COLLECTED Ifire sitation,.school, 5th st., etc.)
COLLECTED BY: (Name)",
TYPE OF (36) 10 Municipal o Industrial i" Private
,SYSTEM Community or 2 Commercial or 3 0- Residence
SEND REPORT T& Print lull Nome, Address and Zip Cadet
SOURCE TYPE :371 WASHINGTON
Combination
10 Surface;. 2 0 Well; 3 0 Spring; 4 0. Purchased; , 9 0 or Other
TYPE OF SAMPLE (38) (CHECKONEONLY) New Swimming Swimming
. -30 ;Mciin�40 Pool.- 5 0 Beach
1 GD, Drinking 2 0 Raw
Water
S ito Shellfish Other
u�nveyry 17'b 9' e Y')
60 so Seawater 8 CD 'Study 0 (S� cif L
IS THIS SAMPLE A FOLLOW-UP TO A (39)
PREVIOUS NON -CONFORMING SAMPLE? 10 Yes 0 0 No
IF YES, GI�E PREVIOUS LAB. NO.
,69) SYSTEM TREATMENT lCheck only for Drinking Water Samplesl
r 1 0 None; 2 0 Chlorination; 3 0 Filtration; 4 0 Fluoridation;
�t 0 Other ISPecify)
REMARKS:
LABORATORY RESULTS
SEE REVERSE SIDE OF PINK COPY FOR INTERPRETATIONS
A. COLIFORMS PER I 00ml
C. FECAL COLIFORM
[] RESUBMIT.SAMPLE
5 TUBE MPN TEST (401
/looml
Test Unsuitable Becouser
1'. El - 0/5 = <2.2
MPN_
170) 1, EJ Confluent Growth
2 = 2.2
"7-601 - * - r E
2. C3 TNTC
MF /loom]
3,0 Excess Debris
3.[]- 2/5 5.1
4
4.[:]- .3/5 9.2
(61-64) - 0 -
El RESUBMIT SAMPLE -7,.731
5.0 .! 4/5 16
Sample Rejected Because: lCheck One Or More)
6. 5/5 > 16
1. 0 Sample.,
icto Old
MF I ooml
2. E] Fee Not Provided
141-44) E
3. 0 Sample Received Too Late In Week
_<:I)
MPN DILN. TESTS
4. [:] Insufficient Information Provided.
/1,00 ml
Please Read Instructions O-n Form.
E
5. [1 Not in Proper Container
(45-48) - -
6. [1 Leaked Out
B. STD. PLATE COUNT
7. El Other (Specify)
/ml
i (53-56Ii7- 0 E (53-56)-li- 0 L__
REMARKS:
A (75-80)
� A E&TIM DATE & TO/ DATE
/ M A CO 5�
EC E I VED *11 C05,P6ET, E D RECEIVED
WATUR SUPPLIER COPY WATER SUPPLIER CUP'
r
Sffte of Wasfiington
Department of Social and,Health Services
Healt h S a rk i c.U_Q ion B17-9
Smith T r 7fe`altle, Washington 98104
WATERBACTER IOLOGICAL ANALYSIS.
READ INSTRUCTIONS ON BACK OF GOLDENROD COPY
IF INSTRUCTIONS ARE NOT PROPERLY FOLLOWED,
.SAMPLE WILL BE REJECTED.
FOR LAB USE ONLY CO, -CITY 46-10) 11 1� 141
LAB. NO. ti--?i I
I I
DATE COLLECTED (15-20) DATE.STARTED 1271 (28,�ol
Mont/ Day yea, (2 1 -261
� I . " "
Vs / . H
TIM� OF DAY � (6a) LD ' NO� (Public Systems) COUNTY NAME
COLLECTED 'CdAM 1 1311 1321 (33), [� (34) 1 135)
0 PM
NAME OF WATER SYSTEM CIRCLE CLASS
1 1-1 -2 3 4
SYSTEM ADDRESS
LOCATION WHERE SAMPLE WAS , COLLECTED (fire siation, school, 5#h st., etc,)
COLLECTED BY: (Name)
TYPE OF (36) Municipal o InclU trial or 3 Private
SYSTEM Community or 2 Commercial 0 Residence
cS END REPORT TO: (Print Full Name, Address and Zip Code)
4
WASHINGTON
SOURCE TYPE :37) Combination
10 Surface; 2 0 Well; 3 0 Spring; 4 0 Purchased; 9 0 or Other
TYPE OF SAMPLE (38) (CHECK ONE ONLY' New Swimming Swimming
I Drinking Water 2 0 Raw 3 0 Main 4 0 Pool 50 Beach
Water
Sanitary Shellfish 0, Other
60 Survey 7 0 Seawater 80 Study (Specify)
IS THIS SAMPLE A FOLLOW-UP TO A (391
PREVIOUS, NON -CONFORMING SAMPLE? IOYes 00No
IF YES, GIVE PREVIOUS LAB. NO.
,69) SYSTEM TREATMENT (Check only for Drinking Water Samples)
1 0 None; 2 P Chlorination;
3 0 Filtration; 4 0 Fluoridation;
9 0 Other (Specify)
*REMARKS:t...,
LABORATORY RESULTS
SEE REVERSE
SIDE OF PINK COPY FOR INTERPRETATIONS
A. COLIFORMS PER 100ml
C. FECAL COLIFORM
[I � RESUBMIT SAMPLEI
5 TUBE MPN TEST (40)
1 00ml
Test Unsuitobie Because:
1.0- 0/5 =<2.2
MPN
(.,a) 1. El Confluent Growth
2.[]- 1/5 = 2.2
(57-60) - 0 - E .-
.2. 0 TN ' TC
MF /100ml
3.0 Excess Deb!�'is
10- 2/5 = 5.1
0 E
40
4. Ej - 3/5 = 9.2
161-64) - - -
.
RESUBMIT SAMPLE .. ... ..
5.[3-. 4/5 = 16
Sample Rejected Because: (Check One Or More)
1 6. [1- 5/5 = >16
1, El Sample Too Old
MF ,-) /100mi
(41-44)_j�. Q E I,,:?
MPN DILN. TESTS
/100 ml
A
(45 48) - 0 - E -
,B. STD. PLATE COUNT
/ml
(53 -!Lp) E
'REMARKS;
. 2. 0 Fee Not Provided
3. F1 Sample Received Too Late In Week
4. 0 Insufficient Information Provided.
- Please Read Instructions On Form.
5. O'Not In Proper Contoin&
_P6. 0 Leaked Out
7. 0 Other (specify)
DATE & TIME (75-80)
RECEIVED DATE TED
WA -FL -It SUPPLIER COPY
StIp of Washington
Department of Social and Health Services
Division B17-9
SmitbTovva�ii@&-WAhingtn 98104
-VATE,R,13 3GICAk.,,ANALYSIS
ACTERIOU
READ INSTRUCTIONS ON BACK OF GOL E ROD COPY
IF INSTRUCTIONS ARE NOT PROPERLY FOLLOWED,
SAMPLE WILL BE REJECTED.
FOR LAB USE ONLY CO. --CITY
LAB. NO., (1q)
_5 U
BAYETJOLLECTED s.io) DATE STARTED 42 1� 28-301
Mont Day Y�ear 121-26�_'/
TIME OF DAY E;pa), I.D. NO APublW Systems) COUNT NAME
COLLECITIED AM 1 (3,11 132) !331 It I
, - I . 1 34)1 3
OPM2 -
NAME OF WATER SYSTEM CIRCLE CLASS
1 2 3 4
SYSTEM ADDRESS
LOCATION WHERE S�EWAS 66ILLECTED (fire slailiori, -school, 5th st., etc.)
COLLECTED BY: (Name)
TYPE OF (36) 10 Municipal or 2 0 Industrial "or 3 0 Private
SYSTEM,- * �, . Community Commercial Residence
SEND REPORT TO: (Print Full Name, Address and Zip Code)
WASHINGTON
SOURCETYPE :37) Combination
10 Surface; 2 0 Well; 3 0 Spring; 4 0 Purchased; ., 9 0 or.Other
TYPEOFSAMPLE 1381 (CHECKONEONLY) New Swimming Swimming
1, Drinking Water 2 0 Raw
Water -3 0 Main--4 0 Pool -7- 50 Beach
Sanitary Shellfish 0 0 her.'
6 0 Survey 7 0 Seawater 8 0 Study (Strecify)
IS THIS SAMPLE A FOLLOW-UP TO A (39)
PREVIOUS, NON -CONFORMING SAMPLE? 10 Yes 0 No'
IF YES, GIVE PREVIOUS LAB. NO.
,6g) SYSTEM TREATMENT (Check only for Drinking Water Samples)
10 None; 2,0 Chlorination; 3 0 Filfrati,an;' 4 0 Fluorid otion;
1
�? 0 Other ISpec'ify)
REMARKS:
LABORATORY RESULTS
SEE REVERSE SIDE OF PINK COPY FOR INTERPRETATIONS
A. COLIFORMS PER 1 00mi
C. FECAL COLIFORM
F-1 RESUBMIT -SAMPLE
5 TUBE MPIN TEST (40)
/100MI.
Test Unsuitable Because;
1. . 0/5 = �2.2
MPN
(70) 1. 0 Confluent Growth
2.[)- -1/5 = 2.2
(57-60) - E -
� 2. [1 TNTC
MF_ /100ml
3. El Excess Debris
3. [1- 2/5 = 5.1
E
4 E]
4. 3/5 = 9.2
(61-64) -
0 RESUBMIT SAMPLE 171-7.1
5. El - 4/5 = 16
Sample Rejected Because: (Check One Or More)
6.(:]- 5/5 = ?'IT6
1. Sample Too Old
MF I 00-ml
2. 0 Fee Not Provided
(41-44) 3. Sample Received Too Late In Week
MPN DILN. TESTS' 4. 0 Insufficient Information Provided.
/100 ml Please Read Instructions On Form.
E 5. Not In Proper Container
B. STD. PLATE COUNT 6. El Leaked Out
7- Other (Specify)
/ml
(53-56)- E
REMARKS:
175-801
DATE & TIME DATE
RECEIVED COMPtEt'E
WATER SUPPLIER-COP)l