ST0701-LR100115Water Bacteriology Report / Chain of Custody R ertnrd
City of Lewisville Environmental Control Services Laboratory
S am p I es - Kc — cepted
Monday - Thursday
Customer Comments
Report #
1 897 Treatment Plant Rd., Lewisville, TX 75057
J ! phone (972) 219 -3548 fax (972) 219 -3506
8:00 A.M. - 12:00 Noon
0110- 9 7>
Lab ID 48146 EPA Lab Code TX01143 Sam le Bottle I.D. # I ��
Customer Name:
\ 1 - /` a. /t Project#
L 14 Project Name:
7 Y
Customer Address: Project Address: Contact:
� !
C
City, State, Zip _
ity, State, Zip 1 .� •T�
n
Phone #
Phone # Fax # p,. j �f�
v
ater System ID#
Sample Collection Information
c
r..
Water Sampling Information
Analytical results
Sample ID
p
°—
i s
.,-,
D
, ;
Chlorine Results
Type of Sample
Water
Total
E. coli
(Lab Use Only)
m a
N
�`
Collected
Source
Colirorm
m u
Sample ID
Date
Time
E
Cn
(Point of Collection)
Collected
Collected
z
a>
Residual
s
°
°
-o
N E
d
+-
n
E
(D
o
E
C3
o
2
m
m
ro
ro
Q
°
o
>
W
>
W
C1
m
c!1
E
ill
a
d
u_
ro
o
—
m
N
❑
a
CO
o
U
Cl-
cr
_
Cn
cd
rn
cJ
W
C
>
0
Z
>
ll�
Z
m
_ _
l v
Q
G
W
.
V
L r t
X
G
W
it
�<
X
G
W
X
G
W
X
G
W
X
G
W
X
G
X
G
j
X
G
X
Sample Custody Documentation
Samplers Name:
Print
# of Bottles
Relinquished by: ,, /
�� �W
# of bottles
Date /
1
�.>�
Collected
Signature ,�'e.�
relinquished
<
Time
Received By:
Print
# of Bottles
Date / Time
Relinquished By:
# of bottles
Date /
eceived
Received
Signature
relinquished
Time
Received for Lab:
Signature
k c�—& L
# of Bottles
received
Date / Time 1
Received 1- - ` D
Lab
C mmen s
�QW
,� U -- •vr
Quality Control Data
Date / Time Analysis:
Analytical Method: Sample 0 Form Incomplete ❑ Non - Coliform bacteria / silt present
Colllert TM
Approved By:
, t
f''
— - 13 iI;J�(�1�
El' (SM9223) Flags: ❑ Sample Outside Hold Time ❑ Quantity too great to permit agitation
[]Excessive
SM 20th Edition Chlorine Present ❑ Quantity insufficient for analysis
❑ Unsuitable Container ❑
Date: i {�
oairiNre r yNatat: U - urau; aampie matrix: w - water; Preservation: I - samples iced down 1. Thermometers /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