ABCDEFGHIJKLMNOPQRSTUVWXYZ
1
Chain of Custody Record
2
Customer:
E-mail address:
SDG Number:
3
Contact/Report to:
Project Name:
Sampled by:
4
Phone:
Project Location:
PO Number:
5
Fax:
Project Number:
Page ___ of ___
6
Analysis Requested
7
PreservativeFieldDate/Time:
8
Lab
9
Field Sample IDDate SampledTime SampledNo. of Bottles Matrix *
No. Encores (EPA 5035)
Sampling Remarks/ Comments
10
11
12
13
14
15
16
17
18
19
20
21
Relinquished by:Received by:
Date/Time:
Deliverables:
Receipt Temp (°C):______
Turnaround Time:
22
Relinquished by:Received by:
Date/Time:
I II III CLP EDD
On Ice N/A Same Day
STD Next Day 2-Day Other_____
23
Relinquished by:Received by:
Date/Time:
Custody Seals:
Comments/Special Instructions:
24
Relinquished by:Received by:
Date/Time:
Sample Cooler
25
Relinquished by:Received by:
Date/Time:
Delivered by client
26
Relinquished by:Received by:
Date/Time:
CAS Courier
27
* DW = Drinking Water | GW = Groundwater | SW = Surface Water | W = Water | WW = Wastewater | S = Soil | SED = Sediment | SL = Sludge | O = Oil / Fuel
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100