Embed Size (px)
Citation preview
DATECOLLECTED
FIELD ID(Optional)
TIMECOLLECTED
SAMPLE ID / DESCRIPTION(List unique samples once) ANALYSIS REQUESTED COMMENTS SAMPLE NO.VIA
L
GL LITE
R
GLL+
H2SO
4
PL LITE
R
PLL+
HNO3
PLL+
H2SO
4
PL25
0+H2
SO4
PL25
0
PL25
0+HN
O3
BACTER
IA
11MATRIX:
CLIENT NAME:
ADDRESS1:
ADDRESS2:
CITY / ST / ZIP:
PHONE:
WEBSITE / EMAIL:
PROJECT INFORMATION:
FAX:
:)tneilC naht rehto fI( OT ECIOVNI:)tneilC naht rehto fI( OT TROPER
CHAIN OF CUSTODY RECORD AND ANALYSIS REQUEST1602 Clare Avenue, West Palm Beach, FL 33401 p: 561 833 4200 e: [email protected]
7516643198
DW, WW, NPW, GW, OTHER
TEMP:T.A.T.:
LAB USE ONLY
Form date: 03/19/13
NOTES:FIELD ID: (Optional) List a Field ID if applicable. Not the sample as a unique Sample Label / Client ID.
MATRIX: DW: Drinking Water; WW: Waste Water; NPW: Non-potable Water; GW: Ground Water; Other: Please list.
BOTTLES: In the columns provided, list the number of sample bottles for each unique sample.
ANALYSIS REQUESTED: Note that multiple analyses may be performed on each unique sample.
*Please call 561.833.4200 for questions about this form.
List total # of bottles per bottle type:
RELINQUISHED BY (SIGN; PRINT INITIALS):
SAMPLED BY (SIGN; PRINT INITIALS):
DATE: TIME:
DATE: TIME:
DATE: TIME:
TIME: RECEIVED BY (SIGN; PRINT INITIALS):
:)SLAITINI TNIRP ;NGIS( YB DEVIECER :)SLAITINI TNIRP ;NGIS( YB DEHSIUQNILER
:)SLAITINI TNIRP ;NGIS( YB DEVIECER :)SLAITINI TNIRP ;NGIS( YB DEHSIUQNILER
CARRIER/WAYBILL ID#:
DATE:
TIME: DATE:
TIME: DATE:
C
CLIENT: _________PROJECT: _________
LAB USE ONLY
INVOICE: _________163/2/2015 12:23:43 PM 16 CHAIN OF CUSTODY
