Bacteria COC Form

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BACTERIOLOGICAL EXAMINATION OF WATER FROM PUBLIC WATER DISTRIBUTION SYSTEM
RED TYPE TO BE COMPLETED BY COLLECTOR
PWSID Number:
County Name:
Compliance Date:
Public Water System Name:
Phone:
Fax:
Report to Be Mailed To:
Report to Be Mailed To: (if different from report address)
Client Name:
Client Name:
Attn:
Attn:
Address:
Address:
City/State/Zip:
City/State/Zip:
Lab ID#: 00442 CM
Analyst(s) Name:
SAMPLE HISTORY
COLLECTION DATA
RECEIVING DATA
ANALABS, INC.
P.O. Box 1235
Crab Orchard, WV 25827
304-255-4821
Date Reported:
Contact Person:
Lab Performing Analysis: Analabs, Inc.
Print Form
SAMPLE RESULTS
Chlorine
Residual
ANALYSIS DATA
COLIFORM
(P or A)
FREE or
TOTAL
Free
(mg/L)
Date
Time
Initials
Date
Time
Initials
Date
Time
Initials
Sample Location
(circle one)
pH
Lab No.
Total
Fecal/
E. coli
METHOD1
TYPE 2
Raw Sample:
REMARKS (FOR LAB USE ONLY): (i.e. Any samples not meeting “Transportation Conditions” standards according to EPA regulations, etc.)
SPECIAL REPORTING INSTRUCTIONS:
Report to EHS (State Health Dept.)
1. Standard Methods for the Examination of Water and Wastewater, 18th or 19th Edition: 1-9221A; 2-9221B; 3-9222A; 4-9222B; 5-9222C; 6-9221D; 7-9223. Note any other approved method.
2. Types of Samples: 1-Compliance; 2-Repeat; 3-Replacement; 4-Speacial Purpose