This section captures critical facility and sampling point identification data to ensure traceability and regulatory compliance. Accurate documentation is essential for trend analysis and incident investigation.
Facility Legal Name
Facility Complete Address
Building Identifier Code
Water System Type
Open Recirculating Cooling Tower
Closed Loop Cooling System
Evaporative Condenser
Heat Rejection System
Hybrid Cooling System
Other
System Asset ID Number
Sample Collection Date & Time
Sample Collection Point Identifier
Sample ID Number (Chain of Custody)
Maintenance Engineer Name
Engineer Certification/License Number
Ambient Temperature at Time of Sampling (°C)
Weather Conditions
Is this a routine scheduled sample or unscheduled/event-driven sample?
Unscheduled Sample Trigger Reason
Post-maintenance verification
Suspected contamination event
Occupant complaint
Visual inspection anomaly
Previous test failure
Regulatory directive
Other
Scheduled Sampling Frequency
Upload Photo of Sampling Point Location
Upload Photo of Sample Label
Upload Chain of Custody Document
Accurate measurement of physical and chemical parameters is fundamental to assessing water treatment efficacy and microbial control. All measurements must be taken using calibrated equipment under consistent conditions.
Critical Water Quality Parameters - Multi-Point Measurement
Measurement Location | Water Temperature (°C) | pH Value | Conductivity (µS/cm) | Total Dissolved Solids (ppm) | ORP (mV) | Free Chlorine Residual (ppm) | Total Chlorine Residual (ppm) | Bromine Residual (ppm) | ||
|---|---|---|---|---|---|---|---|---|---|---|
A | B | C | D | E | F | G | H | I | ||
1 | CT Basin (Return) | |||||||||
2 | CT Basin (Sump) | |||||||||
3 | Makeup Water Line | |||||||||
4 | Bleed/Drain Line | |||||||||
5 | Remote Storage Tank | |||||||||
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7 | ||||||||||
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9 | ||||||||||
10 |
Are all measured parameters within the acceptable control ranges specified in your Water Management Plan?
Continue with routine monitoring and documentation.
Which parameters are out of specification? (Select all that apply)
Temperature
pH
Conductivity/TDS
ORP
Free Chlorine
Total Chlorine
Bromine
Other chemical parameter
Measurement Equipment Make & Model
Is measurement equipment calibration current and valid?
Explain calibration status and corrective action taken
Last Calibration Date
Target Biocide Concentration (ppm)
Actual Biocide Concentration (ppm)
Chemical Treatment Products Used (Name, Active Ingredient, Dosage Rate)
Are scale/corrosion inhibitor levels adequate?
Describe inhibitor deficiency and planned corrective action
Upload Photo of Measurement Device Display Readings
Upload Photo of Chemical Feed System
Laboratory analysis provides definitive evidence of microbial control efficacy. This section documents analytical results, compares them against baseline and action levels, and calculates contamination deltas to assess trends and trigger response protocols.
Accredited Laboratory Name
Laboratory Accreditation Number
Laboratory Sample Receipt Date
Laboratory Analysis Date
Sample Age at Analysis (Hours from collection)
Microbial Test Panel Results & Historical Comparison
Test Parameter | Test Method (e.g., ISO 11731) | Current Result (CFU/mL or CFU/L) | Previous Result (CFU/mL or CFU/L) | Contamination Delta (%) | Action Level (CFU/mL or CFU/L) | Exceeds Action Level? | Result Interpretation | ||
|---|---|---|---|---|---|---|---|---|---|
A | B | C | D | E | F | G | H | ||
1 | Heterotrophic Plate Count @ 35°C | 10000 | |||||||
2 | Legionella spp. (Culture) | 1000 | |||||||
3 | Legionella pneumophila (Culture) | 100 | |||||||
4 | Pseudomonas aeruginosa | 10000 | |||||||
5 | Total Aerobic Bacteria | 100000 | |||||||
6 | Fungi (Yeast & Mold) | 1000 | |||||||
7 | Algae (Microscopic Count) | 1000 | |||||||
8 | Other (specify) | ||||||||
9 | |||||||||
10 |
Do any test results exceed established action levels?
Which parameters require immediate corrective action? (Select all that apply)
Heterotrophic Plate Count
Legionella spp.
Legionella pneumophila
Pseudomonas aeruginosa
Total Aerobic Bacteria
Fungi
Algae
Multiple parameters
Is there a statistically significant upward trend in microbial counts compared to previous 3 sampling events?
Rate the severity of the contamination trend (1 = Slight increase, 5 = Severe escalation requiring immediate shutdown)
Laboratory Analytical Comments & Observations
Sample Transport Temperature (°C) - If Monitored
Was chain of custody maintained throughout sample transport?
Describe custody breach and potential impact on results
Upload Laboratory Report (PDF)
Upload Photo of Sample Condition Upon Receipt
When microbial contamination exceeds action levels or shows concerning trends, immediate corrective action is required. This section documents the emergency response plan, including system flushing, chemical shock treatment, and safety protocols to restore microbial control.
Is corrective action required based on Section 3 results?
Corrective Action Priority Level
Immediate (within 2 hours)
Urgent (within 24 hours)
Standard (within 72 hours)
Precautionary (within 1 week)
Continue routine monitoring. Document any changes in system operation that may affect future results.
Has the system been shut down or placed in reduced operation mode?
Provide shutdown rationale and operational impact assessment
Detailed Corrective Action Procedure Description
Chemical Shock Treatment Dosage Calculation & Application Log
Chemical Product Name | Active Ingredient & Concentration | System Water Volume (m³) | Target Dosage (ppm or mg/L) | Actual Product Quantity Added (L or kg) | Measured Final Concentration (ppm) | Contact Time (hh:mm) | Safety Data Sheet Reviewed? | ||
|---|---|---|---|---|---|---|---|---|---|
A | B | C | D | E | F | G | H | ||
1 | |||||||||
2 | |||||||||
3 | |||||||||
4 | |||||||||
5 | |||||||||
6 | |||||||||
7 | |||||||||
8 | |||||||||
9 | |||||||||
10 |
System Flush Procedure Details (Flow rates, duration, discharge location)
Was system decontaminated/disinfected prior to restart?
Describe decontamination method and verification
Were all safety protocols followed during chemical handling?
Describe safety incidents or protocol deviations
Personal Protective Equipment Used (Select all that apply)
Chemical-resistant gloves
Safety goggles/face shield
Respirator/face mask
Chemical-resistant suit/apron
Steel-toed boots
Emergency eyewash station available
Spill containment kit on-site
Wastewater Discharge Permit Number (if applicable)
Was discharge to sanitary sewer approved by local authorities?
Explain alternative disposal method and environmental compliance measures
Corrective Action Start Date & Time
Corrective Action Completion Date & Time
Has post-treatment sampling been scheduled to verify effectiveness?
Post-Treatment Sample Collection Date
Explain why post-treatment verification is not required or scheduled
Effectiveness Verification Criteria & Success Metrics
Upload Photo of Chemical Dosing Equipment Setup
Upload Photo of System During Flush Procedure
Upload Safety Data Sheets for All Chemicals Used
Final review and authorization by facility management and health authorities ensures accountability and regulatory compliance. This section formalizes approval of the testing protocol, results interpretation, and any corrective actions taken.
Summary of Findings & Actions Taken
Risk Assessment Matrix - Rate the following risk factors
Very Low Risk | Low Risk | Moderate Risk | High Risk | Critical Risk | |
|---|---|---|---|---|---|
Likelihood of microbial regrowth within 30 days | |||||
Potential for human exposure to aerosolized bacteria | |||||
System complexity and dead-leg potential | |||||
Historical compliance performance | |||||
Effectiveness of current Water Management Plan |
Does this result require notification to health authorities?
Health Authority Name
Have health authorities been notified (if required)?
Health Authority Notification Reference Number
Explain notification delay and planned timeline
Are there any occupant notification requirements?
Notification Recipients (Select all that apply)
Building occupants
Tenant representatives
Facility staff
Contractors
Visitors
Public health officials
Insurance provider
Legal counsel
Maintenance Engineer Digital Signature - Full Name
Maintenance Engineer Signature
Engineer Signature Date & Time
I certify that all information in this form is accurate and complete to the best of my knowledge
Explain any uncertainties or incomplete data
Director of Facilities - Full Name
Director of Facilities - Title/Position
Director of Facilities Approval Signature
Director Approval Date & Time
Does the Director approve the corrective action taken (if applicable)?
Specify required modifications or additional actions
Director Review Comments & Additional Instructions
Has this incident been logged in the facility's Water Management Plan records?
Explain record-keeping deviation
Water Management Plan Document Version/Revision Number
Next Scheduled Sampling Date
Health Authority Inspector Name (if applicable)
Health Authority Inspector Signature (if applicable)
Health Authority Inspection Date & Time (if applicable)
Upload Supporting Documentation (Photos, Lab Reports, SDS, etc.)
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