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I
Chain of
Custody Record
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QUA 4124 0797
Client Project Manager 1
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of
Address Telephone Number (Area Code)/F Number Lab Number
C it
y State Zrp Code Site Contact Lab Contact
Project Name J ]\ ! Carner/Waybill Number
Contract/Purchase Order/Quote No.
Sample 1. 0. No. and Description
(Containers for each sample maybe combined on one line)
Matrix
Containers &
Preservatives
Date Time o _ "e n el `^ o = 0 a s 0
N i
Analysis
more space
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(Att
ach list if
is needed
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Chain of Custody Numbe
Page o1
Special Instructions/
Conditions of Receipt
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L1 Non -Hazard q Flammable El Inifant El Poison B
I p
Unknown
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7 Realm Io Client q Disposal By Lab q Archive For Months
(A lee maybe assessed it samples are retained
longer than 3 months)
Turn Around Time Required\^ /
-/
--D o! hlours El Hours El 7Days El 14 Days ^J 21 Days
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l
q I Ulher f I ^ I IJ Kn
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QC Requirements (Speci fy)
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..- .. .............. ..r 3are
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elinquisheOBy Date Time 2 Received By Data Time
Relinquished By Date Time 3. Receiver) By I Date I Time
DISTRIBUTION: WHITE - Stays with the Sample; CANARY - Returned to Client with Repo"; PINK - Field Copy