ST0301A-LR100701Water Bacterioloav Renort / Chain of Custndv RPCnrd
City of Lewisville Environmental Control Services Laboratory
S amples Acce
Monday Thursd
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Customer Comments
Report #
LEWISVIL E 897 Treatment Plant Rd., Lewisville, TX 75057
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i71- 3av -35_
S wdw,�aI phone (972) 219 -3548 fax (972) 219 -3506
8:00 A.M. - 12:00 Noon
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Lab ID 48146 EPA Lab Code TX01143
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ustomer Name: , ! 4 ., ti h
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ustomer Address: L l 9 /C` Rd /
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Contact
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Phone #
Phone # _ �., Fax
ater System ID#
Sample Collection Information
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Water Sampling Information
Analytical results
Sample ID
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Chlorine Results
Type of Sample
Water
Total
E. cor
(Lab Use Only)
N
Collected
Source
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¢
Coliform
2,
m m
E
Sample ID
Date
Time
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£
N
a
X
2
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Q
(Point of Collection)
Collected
Collected
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Residual
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E
V
E
n
E
CL
E
(mg /L)
m
2
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N
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3
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W
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W
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W
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W
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W
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G
W
X
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W
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W
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W
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W
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Sample Custody Documentation
S amplers Name: r /
Print �P a , �`
# of Bottles
Collected
Relinquished by:
bottles
Date /' - (- / CJ
�» a � 5 t
Signature
L#of
nquished
Time
Received By:
Print
# of Bottles
Date / Time Relinquished By:
# of bottles
Date /
received
Received Signature
relinquished
Time
Received for Lab: /
ignature /�
P
M of Bottles
Date / Tim 0 '� y O.7.�
— + —' o rv/
Lab
IS ` (�
received
Received
Comments
Quality Control Data
Date / Time Analysis:
Mnalytical Method:
Sample ❑ Form Incomplete ❑ Non - Coliform bacteria / silt present
Approved By:
CoI lert T11 (SM9223)
Flags: ❑ Sample Outside Hold Time ❑ Quantity too great to permit agitation
SM 20th Edition
❑ Excessive Chlorine Present ❑ Quantity insufficient for analysis
❑ Unsuitable Container ❑
Date:
Revision 1.3 i
7/�/ Z '-'�
Sample t ype(s): v - Grab; Sample 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 NELAP 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.
✓$/2009
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