ST0701-LR100127Water Bacteriology Report / Chain of Custody R ecord
City of Lewisville Environmental Control Services Laboratory
S amples Accepted
Monday - Thursday
Customer Comments
Report #
I,EVVISVI L 897 Treatment Plant Rd., Lewisville, TX 75057
t ^w RESULT-5
fit; T NR IL
D ,,,,,p r.
, a � � (
phone (972) 219 -3548 fax 972) 219 -3506
8:00 A.M. - 12:00 Noon
W, rl(g Lip
(% �
i� `�
Lab ID 48146 EPA Lab C ode TX01143
Sam le Bottle I.D. #
h?
ustomer Name:
Project Name: - `7 - (V i.)
Project#
ustomer Address:
Project Address:
Contact:
ity, State, Zip L. r i A
iry, State, Zip
Phone #
hone # �. Z Fax #Q A
ater System ID#
Sample Collection
Information
Water Sampling Information
Analytical results
co
N
N co
Chlorine Results
Type of Sample
Water
Total
E. Coli
Sample ID
as
Collected
Source
E
a
Coliform
Lab Use Oniyy
Sample ID
Date
Time
E
a
x
L
Q LL
E
(Point of Collection)
Collected
Collected
'
Z
2
d
Residual
c
4
s
L
o
a
^
(mg /L)
—
U
E
m
v
o
U o
c
c
o
E
m <n
O
X1
m
U)
E n
I
m
Cn
Q)
LL
m
-
3
X
y
a
(n
U
a
E
to
—
m U
W
>
LL
t°
Z
>
LL
LL
Z
y
U)
— - -- -
G
W
X
-
G
W
X
-—
G
W
X
G
W
X
G
W
X
- -- -
G
W
X
G
W
X
r �
GW
1
X
Sample Custody Documentation
Samplers Name: # of Bottles
rint
Relinquished by:
# of bottles
Date/
U Collected
Signature � (' �,,/ It sr
relinquished
%
Time alyrf
Received By:
# of Bottles
Date / Time
Relinquished B
9 Y:
# of bottles
Date /
rint
received
Received
Signature
relinquished
H
Time
Received for Lab:
ignature
# of Bottles
Z
Date / Time 14, 9 ,_. ��
0 �
Lab
�,
received
Received
e (f
Comments
Quality Control Data
Date / Time Analysis:
C
❑ Form Incomplete Non bacteria! silt present
E]
Approved By:
I m- 0 il e rt TM (SM9223)
Flags: ❑ Sample Outside Hold Time ❑ Quantity too great to permit agitation
�
SM 20th Edition
1
❑ Excessive Chlorine Present ❑ Quantity insufficient for analysis
❑ Unsuitable Container ❑
Date:
Sample Type(s): G - Grab; Sample Matrix: W - Water; Preservation: I - samples iced down 1. Thermometer SIN: 51030428
a o White Ori inal : Returned to Customer as a report / Chain of Custody record; Yellow: Laboratory Co File Co Copy p
( 9 ) P Y ry py ( Copy); Pink: Customer Co at time of drop off h.
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