Security Fire Systems-LR170605Water Bacteriology Report / Chain of Custody Record
City of Lewisville Environmental Control Services Laboratory
Samples Accepted
Customer Comments:
Repot #
LEWISVILLE 897 Treatment Plant Rd., Lewisville, TX 75057
Monday - Thursday
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Lab ID 48146 EPA Lab Code TX01143
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Sample Collection
Information
Water Sampling
Information
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Analytical
Results
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Chlorine Results
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Sample Custody Documentation
Samplers Name: q n �
# of Bottles
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Relin uished B :
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# of Bottles
Date
Collected
Signature nLe;,
Relinquished
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ReceivedBy:
#of Bottles
Date/Time
Relinquished By:
#cf Bottles
Date/
Print
Recelved
Received
Signature
RClinquishetl
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Time
Receivetl for Lab: J
#of Bottles
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Date/Time
Lab Comments
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Received
Receivetl A
Quality Control Data
Date / Time Analysis:
� /Analytical Method:
TIM
Sample ❑ Form Incomplete ❑ Non -Coliform bacteria /alit present
Flags:
Approved By:
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17 Colilert
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❑ Sample Outside Hold Time ElQuantity too great to permit agitation
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SM 20th Edition
❑ Excessive Chlorine Present ❑ Quantity Insufficient for analysis
❑ Unsuitable Container ❑
Date:
Sample Type(s): G - Grab; Sample Matrix: W - Water; Preservation: I - Samples Iced Down; Lab Chlorine Residual: NO - Not Detected, D - Detected t.Thermometer S/N: 61030428
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