ST1002-LR120221Water Bacteriology Report 1 Chain of Custody Record
Citv of Lewisville Environmental Control Services Laboratory Samples Accepted Customer Comments: Report[ #
.���'.'' a 1,, E 897 Treatment Plant Rd., Lewisville, TX 75057 Monday - Thursday
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Lab PD 48146 EPA Lab Code TX01143 1
Sample Bottle I.Q. #
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Customer Nam. l 44 — , ,4 av c A t e, a' s• 1110 P roject Name:
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ity, State, Zip 7 N - e
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Phone #
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Sample Collection Information
Water Sampling
Information
analytical results
°
Chlorine results
Type of Sample
Collected
water
source
m
Total
Col if
Coll
y
U
Q
rn'
Sample ID
Date
Time
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m
< LL
labusa C3rAy)
(Point of Collection)
Collected
Collected
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0
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Residual
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Sample Custody DcAcumentation
Samplers ame: J /
Print J
# of Bottles
Collected
t�
Relinquished by:
Signature
# of Bottles
Relinquished
Date
Time a ��
Received Ey:
# of Battles
Date 1 Time - Relinquished By:
-
# of Bottles
Date 7
Print
Received
Received Signature
-
.Relinquished
Time
Received for LM:
# of Bottles
Date ! Time o�'l _
Lab
-
Signature
Received
Received
Comments
Quality Control Data
Date f Time Analysis: An Method: Sample ❑ Form Incomplete
❑ Non - Coliform bacteria !silt present
Approved By:
0 TM (SM9223) F l ag s: ❑ Sample Outside Hold
Time
❑ Quantity too great to permit agitation
_ 4h SM 20th Editior Z Excessive Chlorine Present.
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❑ Quantity insufficient for analysis
1. ° `' �` ❑ Unsuitable Container
❑ .Date:
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Sample Types }: G - rab; Sample Matrix: W -Water; Preservation: I - Samples Iced Down; Lab Chlorine Residual: ND - Not Detected, D- Detected
+ White (Original): Returned to Customer as a report 1 Chain of Custody record; Yellow: Customer Copy at time of drop off
Water of satisfactory bacteriological quality should be free from Coliform organisms.
� A ," 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.
Revision 1.4 7I1i2011
1. Thermometer SIN 51936428
to
Effective 711!2011 Page 1 of 1 Bac -T Form