Company Name: Project Manager: Address: City: State: Zip: Email Address : Phone: Fax: Sampler Name Printed: Project Name: List Analyses Requested Sample Identification Sampling Date/Time Matrix Printed Name Signature Company Date Time Relinquished by Received by Relinquished by Received by Relinquished by Received by Turn Around Time & Reporting *All rush order requests must be prior approved. M-M Lab WO # Chain of Custody Record PO Box 1410, Ocean Springs, MS 39566-1410 (228) 875-6420 FAX (228) 875-6423 Preservative: Our normal turn around time is 10 working days __Normal __Next Day* __2nd Day* __Other*______ __Phone __Mail __Fax __Email www.micromethodslab.com Purchase Order #: Sampler Name Signed: Project #: # of Containers QC Level: Level 1 Level 2 Level 3 DCN# F316 Rev.#5 Lab ID# MS00021 LELAP ID # 01960 TNI ID # TNI01397 Grab (G) or Composite (C) Code ID# ID# ID# ID# Field Test Field Test Field Test Field Test W = Water DW = Drinking Water S = Solid SO = Soil SE = Sediment L = Liquid A = Air O = Oil SL = Sludge Preservation: Field Testing Matrix: 1= H2SO4 2= H3PO4 3=NaOH 4=ZnC4H10O6 5=ZnC4H10O6 & NaOH 6=HNO3 7=Na2S2O3 8=HCl 9=NaHSO4 By: _____________________________ Date & Time ___________________ Received on Ice? Y N Thermometer#_________ Cooler #_______ Receipt Temp Corrected(ºC) Sample_____Blank_____Cooler_________ **All Temps are Corrected Values** Physical Address: 6500 Sunplex Drive, Ocean Springs MS 39564 Notes:

Chain of Custodymicromethodslab.com/pdfs/MMLabCOC2017R5.pdfCompany Name: Project Manager: Address: City: State: Zip: Email Address : Phone: Fax: Sampler Name Printed: Project Name:

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Company Name: Project Manager:

Address:

City: State: Zip: Email Address :

Phone:

Fax:

Sampler Name Printed:

Project Name:List Analyses Requested

Sample IdentificationSampling Date/Time

Matrix

Printed Name Signature Company Date Time

Relinquished by

Received by

Relinquished by

Received by

Relinquished by

Received by

Turn Around Time & Reporting

*All rush order requests must be prior approved.

M-M Lab WO #

Chain of Custody RecordPO Box 1410, Ocean Springs, MS 39566-1410 (228) 875-6420 FAX (228) 875-6423

Preservative:

Our normal turn around time is 10 working days__Normal__Next Day*__2nd Day*__Other*______

__Phone__Mail__Fax__Email

www.micromethodslab.com

Purchase Order #:

Sampler Name Signed:

Project #:

# of

Con

tain

ers

QC Level: Level 1 Level 2 Level 3

DCN# F316 Rev.#5

Lab ID# MS00021 LELAP ID # 01960 TNI ID # TNI01397

Gra

b (G

) or

Com

posi

te (C

)

Code

ID# ID# ID# ID#

Field Test Field Test Field Test Field Test W = Water DW = Drinking Water S = Solid SO = Soil SE = Sediment L = Liquid A = Air O = Oil SL = Sludge

Preservation:

Field TestingMatrix:

1= H2SO4 2= H3PO4 3=NaOH 4=ZnC4H10O6 5=ZnC4H10O6 & NaOH 6=HNO3 7=Na2S2O3 8=HCl 9=NaHSO4 By: _____________________________ Date & Time ___________________

Received on Ice? Y N Thermometer#_________ Cooler #_______ Receipt Temp Corrected(ºC) Sample_____Blank_____Cooler_________ **All Temps are Corrected Values**

Physical Address: 6500 Sunplex Drive, Ocean Springs MS 39564

Notes: