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?
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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) | |
|---|---|---|---|---|---|---|---|---|---|
CT Basin (Return) | |||||||||
CT Basin (Sump) | |||||||||
Makeup Water Line | |||||||||
Bleed/Drain Line | |||||||||
Remote Storage Tank | |||||||||
Are all measured parameters within the acceptable control ranges specified in your Water Management Plan?
Measurement Equipment Make & Model
Is measurement equipment calibration current and valid?
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?
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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 | |
|---|---|---|---|---|---|---|---|---|
Heterotrophic Plate Count @ 35°C | 10000 | |||||||
Legionella spp. (Culture) | 1000 | |||||||
Legionella pneumophila (Culture) | 100 | |||||||
Pseudomonas aeruginosa | 10000 | |||||||
Total Aerobic Bacteria | 100000 | |||||||
Fungi (Yeast & Mold) | 1000 | |||||||
Algae (Microscopic Count) | 1000 | |||||||
Other (specify) | ||||||||
Do any test results exceed established action levels?
Is there a statistically significant upward trend in microbial counts compared to previous 3 sampling events?
Laboratory Analytical Comments & Observations
Sample Transport Temperature (°C) - If Monitored
Was chain of custody maintained throughout sample transport?
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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?
Has the system been shut down or placed in reduced operation mode?
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? | |
|---|---|---|---|---|---|---|---|---|
System Flush Procedure Details (Flow rates, duration, discharge location)
Was system decontaminated/disinfected prior to restart?
Were all safety protocols followed during chemical handling?
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?
Corrective Action Start Date & Time
Corrective Action Completion Date & Time
Has post-treatment sampling been scheduled to verify effectiveness?
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?
Have health authorities been notified (if required)?
Are there any occupant notification requirements?
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
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)?
Director Review Comments & Additional Instructions
Has this incident been logged in the facility's Water Management Plan records?
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.)