ST0701-LR091015+) `( q) Fla
Water Bacterioloqv Report / Chain of Custodv R ecord
City of Lewisville Environmental Control Services Laboratory
S amples Accepted Customer Comments
Report #
897 Treatment Plant Rd., Lewisville, TX 75057
Monday - Thursday
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phone (972) 219 -3548 fax (972) 219 -3506
8:00 A.M. - 12:00 Noon
Lab ID 48146 EPA Lab Code TX01143
Sam le Bottle I.D. I - e
ustomer Name: 1, 4 ZZZZ
Project Name:
Project#
ustomer Address: / � �'
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Project Address: l (-Vt4 C
Contact:
State, Zip
,�
ity, State, Zip L7' ,
Phone #
Phone 111 �� — Fax #
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Nater System ID#
Sample Collection Information
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Water Sampling Information
Analytical results
Sample ID
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16
ro
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Chlorine Result
Type of Sample
Collected
Water
Source
Total
Coliform
E. Coli
d
y
a ¢
(Lab Use Only)
Sample ID
Date
Time
E
a
0-
x
a)
rll
v
cn
N
E
(Point of Collection)
Collected
Collected
'
Z
1--
a)
m
d
G)
Residual
°
0
—
c
c
o
E
.,
n
Q
(mg /L)
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o
c) o
°
°
a
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N
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1
m ID
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In
o
U
a
a
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U)
p CJ
W
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ll
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0
Z
0
W
0
Z
c
G
W
X
--
G
W
X
—_
G
W
X
- --
G
W
X
G
W
X
_.—
G
W
X
G
W
X
G
W
X IFEEIE
Sample Custody D cu nta1
Samplers Name:
# of Bottles
Relinquished by:
# of bottles
late/ Ic °
Print
Collected
Signature
relinquished
Time
Received By:
# of Bottles
Date / Time
Relinqui ed By:
# of bottles
Date /
Print
received
Received
Signature
relinquished
Time
Received for Lab:
Signature l�
# of Bottles
received
Date / TimelQ,_ * _C
Received 1
Lab
Comments
i Z r #."
Quality Control Data
Date / Time Ana . sis:
Analytical Method:
Sample ❑Form Incomplete El Non-Coliform bacteria /silt present
Approved B
PP Y :
0 �a' op M
�
Colllert TM (SM9223)
Flags: El Sample Outside Hold Time El Quantity too great to permit agitation
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r
SM 20th Edition
❑ Excessive Chlorine Present ❑ Quantity insufficient for analysis
i� cL
❑ Unsuitable Container ❑
Date:
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