ST0702-LR091111Water Bacteriologv Report / Chain of Custody Record
City of Lewisville Enviro nmental Control Services Laboratory
S amples Accepted
Monday - Thursday
er Comments
Report #
UW A l= 897 Treatment Plant Rd., Lewisville, TX 75057
phone (972) 219 -3548 fax (972) 219 -3506
8:00 A.M. - 12:00 Noon
Lab ID 48146 EPA Lab Code TX01143
ample Bottle I.D. # ��, ►cam __
C ustomer Name: I
Project Name:
Project#
C ustomer Addr s: c i
jj
Project Address:
Contact: �!
C ity, State, Zip ��
ity, State, Zip - '°'�
Phone #
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Phone # „Y _ _ Fax#
vV ater System ID#
Sample Collection Information
Water Sampling Information
Analytical results
°–
M
N
Type of Sample
Water
Total
S ample III ','
�
q1
Chlorine Result
Collected
Source
�
'
¢ Cr
Coliform
E. Coli
c �
tLab Use Only) "
Sample ID
Date
Time
�
B
0
a
5
m
�
ro
Q
o
E
(Point of Collection)
Collected
Collected
z '
T
~
�
w
Residual
�
s
i
°�
0
-0
Q
N E
m
a
°
Q
(mg /L)
ro
2
m
0
0 -
-a
o
W
a
o
W
��° n
C
E
co
E
ro
E
�
o
N
o
3
ro
N
a e
a
c
o
°
ro
_
ro
C)
0
3
0
0
0
0
0
m a
to
to
(n
UP
i-
LL
H
CC
❑
(n
U
W
rn
H W
Z
J
Z
❑
_._
G
W
�>
u
X
v
G
W
X
G
W
X
—
G
W
X
G
W
X
G
W
X
G
W
X
G
W
X
_
G
W
X
G
W
X
Sample Custody Do um tation
amplers Na
^
# of Bottles
/
Re by: //�
# of b
Date
r
Print {�
Collected
<
Si nature ��
elfin uished
Time
Received By:
# of Bottles
Date / Time
Relinquished By:
# of bottles
Date /
Print
received
Received
Signature
relinquished
Time
Received for Lab:
# of Bottles
Date / Time ' ..0
Lab
I si gnature
received
'
Received I e
Comments
Quality Control Data
Date / Time Analysis:
Method:
Sample ❑ Form Incomplete ❑ Non - Colifcrm bacteria / silt present
Approved By:
/ Analytical
�" Colilert TM (SM9223)
Flags: ❑ Sample Outside Hold Time ❑ Quantity too great to permit agitation
j G
xF fn
SM 20th Edition
❑ Excessive Chlorine Present ❑ Quantity insufficient for analysis
Date: (1
I
❑ Unsuitable Container ❑
Sample Type(s): G - Grab; Sample Matrix: W - Water; Preservation: I - samples iced down 1. Thermometer S /N: 51030428
White (Original): Returned to Customer as a report / Chain of Custody record; Yellow: Laboratory Copy (File Copy); Pink: Customer Copy at time of drop off
Water of satisfactory bacteriological quality should be free from Coliform organisms.
Results above relate only to the samples on this report.
ECSL certifies that all results contained in this report were produced in accordance with the requirements of NELAC unless otherwise noted.
This report is intended for the sole use of the customer for whom the work was performed and must be reproduced, without modification, in its entirety.
Revision 1.3 3/3/2009 Page 1 of 1 Bac -T Form