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Chain of
Custody Record
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Client Prolecl Manager
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Address Telephone Number (Area Code) Number Lab Number
City Zip Code Site Contact Lab Contact
Project Name
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ContrectPurchase OrderlQuote No
Sample 1. D. No. and Description
Coma, ners for each sample maybe combined on one line)
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CarriegWaybill Number
Matrix
Date Time °m - o =
Containers 8
Preservatives
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0 30 m
Analysis
more spa
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(A ttach list A
is needed
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Chain or Custody NumbC(
11 0450
Page ^ of
Special Instructions/
Conditions of Receipt
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q NonHaeard q Flammable El Skin Initant El Poison B nknuwn
a' nPie "bposai
Return To Client El Disposal By Lab El Archive For Months
(A lee me
longer fh n 3
ssessed if samples are retained
onths)
Turn Around Time Regmree OC Requirements (Specify) ///
q 4 Hours
in quishe
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q 4 8 Hours El Days El 14 Days 21 Days q Other
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1 3
T
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Received By
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Date
1
1190quished By Date Hme 2 Hecervad fly
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^Aelingwshed By Date Time 3. Received By
Commerns
DISTRIBUTION: WHITE Slays mIh Ibo Sarnple. CANARY -Returned to
1
Time
— —_ — I Date I Time