Fillable 460 East Pearl St. PO Box 937 Jackson, (Teton County Wyoming Government)

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460 East Pearl St. PO Box 937 Jackson, (Teton County Wyoming Government)

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BROWSE TETON COUNTY WYOMING GOVERNMENT (WY) FORMS

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TYPE PUBLIC PRIVATE USFS NPS
SOURCE WELL SPRING POOL SPA
Wt^# (if public) ___ REGULATORY AUTHORITY________________________
TYPE SAMPLE ROUTINE REPEAT SPECIAL_________________________
NAME/ FACILITY _________________________________________________________________
PHYSICAL ADDRESS _______________________________________________________________
SAMPLE LOCATION SPECIFICS (Kitchen, Bathroom,etc…)__________________________________
CHLORINE RESIDUAL ppm_____________________________pH___________________________
COLLECTED BY___________________________ DATE__________________ TIME_____________
(SAMPLES MORE THAN 30 HOURS OLD WILL NOT BE TESTED)
SEND RESULTS TO: EMAIL or MAIL or BOTH
EMAIL:__________________________________________________________________________
MAILING ADDRESS:________________________________________________________________
________________________________________________________________________________
PHONE NUMBER FOR UNSAFE SAMPLES:______________________________________________
FOR LABORATORY USE ONLY
SAMPLE CONDITION: GOOD INSUFFICIENT OLD
SAMPLE ID#___________________ DATE RECEIVED________________TIME__________________
ANALYSIS DATE________________TIME__________________
MF SPC COLILERT-18 OTHER___________________________
VERIFIED COUNT ___________________________
FINAL ANALYSIS: SAFE/ABSENCE UNSAFE/PRESENCE RE-SAMPLE
REMARKS___________________________________________ANALYST______________________
TYPE PUBLIC PRIVATE USFS NPS
SOURCE WELL SPRING POOL SPA
Wt^# (if public) ___ REGULATORY AUTHORITY________________________
TYPE SAMPLE ROUTINE REPEAT SPECIAL_________________________
NAME/ FACILITY _________________________________________________________________
PHYSICAL ADDRESS _______________________________________________________________
SAMPLE LOCATION SPECIFICS (Kitchen, Bathroom,etc…)__________________________________
CHLORINE RESIDUAL ppm_____________________________pH___________________________
COLLECTED BY___________________________ DATE__________________ TIME_____________
(SAMPLES MORE THAN 30 HOURS OLD WILL NOT BE TESTED)
SEND RESULTS TO: EMAIL or MAIL or BOTH
EMAIL:__________________________________________________________________________
MAILING ADDRESS:________________________________________________________________
________________________________________________________________________________
PHONE NUMBER FOR UNSAFE SAMPLES:______________________________________________
FOR LABORATORY USE ONLY
SAMPLE CONDITION: GOOD INSUFFICIENT OLD
SAMPLE ID#___________________ DATE RECEIVED________________TIME__________________
ANALYSIS DATE________________TIME__________________
MF SPC COLILERT-18 OTHER___________________________
VERIFIED COUNT ___________________________
FINAL ANALYSIS: SAFE/ABSENCE UNSAFE/PRESENCE RE-SAMPLE
REMARKS___________________________________________ANALYST______________________
BACTERIOLOGICAL WATER ANALYSIS
Teton County Public Health Water Lab
460 East Pearl St. PO Box 937 Jackson, WY 83001
(307)732-8463 or (307)732-8490
BACTERIOLOGICAL WATER ANALYSIS
Teton County Public Health Water Lab
460 East Pearl St. PO Box 937 Jackson, WY 83001
(307)732-8463 or (307)732-8490
_____________
_____________
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460 East Pearl St. PO Box 937 Jackson, (Teton County Wyoming Government)

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Completed 18 July 2020

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