Shake & Shingle 2-LR100317Water Bacteriology Report / Chain of Custody Re cord
City of Lewisville Environmental Control Services Laboratory S amples Accepted
[ Custo mer Comments
Report #
I.T NN MLLE
897 Treatment Plant Rd., Lewisville, TX 75057 Monday
- Thursday
�zn ron.s nava,y a r ry s.
phone (972) 219 -3548 fax (972) 219 -3506 8:00 A.M. - 12:00 Noon
v- 63
Lab ID 48146
EPA Lab Code TX01 143
Sam le Bottle I.D. #
ustomer Name:
Project Name:
Project#
ustomer Address:
t_ ii J
Project Address:
Contact:
ity, State, Zip
ity, State, Zip
�
J.
Phone #
p 2 1
hone #
Fax # -
2
ater System ID#
Sample Collection Information
� Water Sampling Information
Analytical results
Sampte IQ
c
io Chlorine Results Type of Sample Water m
"
Total
E. Coli
(Labussoniy)
d
2)
i-
Collected Source E
C
ME
Coliform
� °)
Sample ID Date Time a
x o
¢ LL
(Point of Collection) Collec Collected z
v c!u Residual
o ° at
o o a E
C�
E (mg /L)
a m m
o
U o
°
O m
m C/)
m m CU
I
2 3 N c c c a � � Cc
u ° 1 rn U (D
m U
°
> j LL N�
°
G
w
cn
u
z t° z
X
_
G
W
X
G
W
X
— —
G
W
X
G
W
X
- - --
G
W
X
-
G
W
X
-- -
I
G
W
X
G
W
X
G
X
Sample Custo
cumentation
Samplers Name:
rint
# of Bottles Relinquished by:
1
# of bottles
Date/ 3—(6— () •_
Collected Signature
relinquished
Time
Receive d By:
# of Bottles Date / Time
Relinquished By:
# of bottles
Date /
rint
received Received
Signature
relinquished
Time
eceived for Lab:
ignature
A f
(1
# of Bottles Date /Time 1 - -I b— V {,�
roceived I Received
Lab
Vvl �l
Comments
� A
Quality Control Data
Date Time Analysis:
alytical Method: Sample [I Form Incomplete
Coliform bacteria / silt present
Approved By:
A� 6 1
�
o `)
`` �� G ��
l�
Colilert T "" (SM9223) Flags:
SM 20th Edition
❑ Sample Outside Hold Ti
❑Excessive Chlorine P sent
Quantity too great to permit agitation
VVV
❑Quantity insufficient for analysis
� �'t✓t M
❑ Unsuitable C tai
❑
Date:
aampie r ypets). b - bra D; Sample Matrix: W - Water; Preservation: I - sam I d dawn 1. Thermometer S /N: 51030428
White (Original): Returned to Customer as a report / Chain of Custody record; Yellow: Laboratory p ile Copy); Pink: Customer Copy at time of drop off
J Water of satisfactory bacteriological quality should be free from liform organisms.
Results above relate only to the samples on thi report.
4 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