1. No category

POLLUTION CONTROL SERVICES
TCEQ NELAP Certificate #
T104704361-08-TX
Chain of Custody Number
DRINKING WATER (P/A) COLIFORM REQUEST & CHAIN OF CUSTODY FORM
Public/Private Water System Identification & Sample Collection Information
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Public Water System ID:
System Type
P W S Name :
Public
Contact Name :
Other:______________________
LABORATORY USE ONLY – DO NOT WRITE BELOW
Client Notification Unsuitable or Failed Sample
Sampler/Person Contacted:
Date/Time Notified:
Address
:
City, State Zip :
Phone Number:
Owner
Operator
Sampler Name:
Alternate Contact Name:
*Replacements / Re-test Samples within 24 hours: Yes
Comments:
Sample Identification/Location
Use Specific Address/Location: NOT SITE #
(Raw Wells Use Source ID for Well Sampled)
Water Source
TX
78209
Groundwater
Fax:
Other:
Surface
Collected
Report Approved by:
Sample Type
Time
Dist
Con
Raw
Well
Special
Chlorine
Res: mg/l
Repeat: Sample # for
Previous Positive
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Chain of Custody
Relinquished By:
Received By:
Relinquished By:
Received By:
Relinquished By:
Received By:
Web Site:www.pcslab.net
e-mail:[email protected]
No
Groundwater w/ Surface Water Influence
Contact#
Contact#
Date
or
Date:
Date:
Date:
Date:
Date:
Date:
Toll Free 1-800-880-4616
Time:
Time:
Time:
Time:
Time:
Time:
1532 Universal City Blvd, Suite 100
Universal City, Tx 78148
Free
Total
Unsuitable
Sample *
Rejection
Criteria #
Date:
Lab Results – Test Method
SM 9223 B
Total Coliform
Present
Absent
E Coli
Present
Absent
PCS Sample #
Stamp1st Sample and COC as same
number
*Unsuitable Sample for Analysis – Rejection Criteria
1) Sample too old. Not received within 30 hours of collection
2) Quantity insufficient for analysis (100 mL. required)
3) Form incomplete / date discrepancy (Circle Errors)
4) Chlorine residual
5) Sample leaked in transit.
6) Other DESCRIBE
210-340-0343
210-658-7903
Z:\COC\PWS_Multi.doc