ST1002-LR120110r o o a Water Bacteriology Report 1 Chain of Custody Record
City of Lewisville Environmental Control Services Laboratory
Samples Accepted
Customer Comment PQ
Report #
897 Treatment Plant Rd., Lewisville, TX 75057
Monday - Thursday
r
cmpK 1, dNrgiry wwzhaws, Phone (972) 219 -3548 Fax (972) 219 -3508
8:00 A .M. - 12:00 Noon
Lab ID 48146 EPA Lab Code TX01143
- Samp le Bottle I.D. #
Customer Name: k ^ t ' "l ±y r�L U 1/'\,
reject Name: 1
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Customer Address: I:~ � �';� CG - V , �� �i ��� _,� A A, .
Project Address: r
Contact
City, State, Zip 11A t f
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City, State, Zip
Phone # -°'`-
Phone # 1 - '7 �"' C'ti Fax # 'f „e"� - r � •
ater System ID# i_
Sample Collection Information
m
Ater Sampling
Information
Analytical results
Type of Sample
water
Total
Chlorine Results
Collected
Source
conform
Coll
Sample ID
Date
Time
M
o
ro
0
Lelx E}�s�7
Collection)
Collected
Collected
x
o
t
E
o
(Point of
F
m
1� t
Residual
,-
U
°
d
E
i Bbl
(mg1L)
O
-
-.
m
o
R
�'
E3
fl.
Q
d
m
Q
`�
t'6
a U
o
0
rn 0
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M
(/)
(n
LL
❑
fn
U
U]
W
LL
0
Z
LL
o
Z
Cn
G
W
G
W
G
W
:'
K
t
G
W
K
G
W
K
G
W
K
G
W
=
K
G
W
K
•i
G
W
".
K
G
W
K.
Sample Custody Documentation
Samplers, me: { t
# of Bottles
Relinquished by: , _ E
# of Bottles
Date)
Print I > -
Collected
Signature 1 r�r,(,
Relinquished
I
Time �
Received Byn r
# of Bottles
Date I Time
Reliri 6
# of Bottles
Date I
Print �+'�
Received
Received
Signature t ` r / t 4 1
Relinquished
Time
Received for
ft of Bottles
Date 1 Time I
.Lab
Signature
Received
r
Received H
Comments
J
4
Quality Control Data
Date 1 Time Analysis:
Analytical Method:
Sample ❑ Form Incomplete ❑ Non- Coliform bacteria r silt present
Approved By:
C011lert
Flags: ❑ Sample Outside Hold Time 116uantity too great to perm itagtation
f 1
SM 20th Edition
❑ Excessive Chlorine Present ❑ Quantity insufficient for analysis
Dale:
❑ Unsuitable Container ❑
Sample Type(s): G - Grab; am pie Matrix: W - Water; Preservation: I - Samples Iced Down; Lab Chlorine Residual: ND - Not Detected, D- Detected
White (Original): Returned to Customer as a report I Chain of Custody retard; Yellow: Customer Copy at time of drop off
Water of satisfactory bacteriological quality should be free from Coliform organisms.
t 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 cusfomer forwhom the work was performed and must be reproduced, without modification, In Its entirety.
Revision 1.4 711/2011
Effective 7/112011
9. Thermometer S1N: 516317428
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