Fairfield Inn-LR170224Water Bacteriology Report/ Chain of Custody Record
City of Lewisville Environmental Control Se vices Laboratory
LEWISVILLE 897 Treatment PlantRd.,Lewisville,TX75057
Samples Accepted
Monday - Thursday
Customer ants K
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Report #
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, Phone(972)2193548 Fax(972)219-3506
8:00 A.M. - 12:00 Noon
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Temperature Correction
Factor'
Sample bottle I.D. # 1 15'1
Lab ID 48146 EPA Lab Code TX01143
Customer Name:
Project Name: Project#
Customer Address:/
Project Address: Contact:
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City, State, Zip �j -
ity, State, Zip Phone #
Phone #
Fax #
later System ID#
Sample Collection Information
Water Sampling
Information
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Analytical
Results
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Chlorine Results
Type of Sample
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E. Coli
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Source
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Sample ID Date Time
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(Point of Collection) Collected Collected
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Custody Documentation
Samplers N
# of Bottles
J
Relinquishetl By:
# of Bottles
Date/ -•- f
Print fJ
Collected
Signature
Relinquishetl
IT me';' / 2�
Received By:
#of BottlesD
ate /Time
Relinquished By:
#of Bottles
Date/
Print
Received
Received
Signature
Relinquished
Time
Receivetl for Lab: , A p @f�
VV
# of Botlles
Data /Tim ` 11
Lab Comments
Si nature M
Receivetl
Received r
Quality Control Data
Date / Time All
Analytical Method:
Sample ❑ Form Incomplete ❑ NomCoiiform bacteria silt present
Approved By:
'®'COlilert T"'(SM9223)
Flags: ❑ Sample Outside Hold Time ❑ Quantity too great to permit agitation
SM 20th Edition
❑ Excessive Chlorine Present ❑ Quantity insufficient for analysis
❑ Unsuitable Container ❑
Sample Type(s): G - Grab; Sample Matrix: W - Water; Preservation: I -Samples Iced Down; Lab Chlorine Residual: ND - Not Detected, D - Detected '.Thermometer S/N:51030428
White (Original): Returned to Customer as a report / Chain of Custody record; Yellow: 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.
Revision 1.6 10/29/2015 Page 1 of 1 Bac-T Form
Effective 12/1/2015