Laboratory Chain Of Custody Form
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1
2Woods End Laboratories
SHIP TO:
290 Belgrade Road
LABORATORY
Mt Vernon ME 04352
CHAIN OF CUSTODY
Phone: 207-293-2457
2016 Form
Fax: 207-293-2488
Your Acct# __________ Previous Lab ID (if any) __________
SAMPLE SUBMISSION FORM
PAGE _________OF________
Company:
CONTACT NAME:
Address:
Collector: [
] Job ID:[
]
PO # (billing accounts)
Credit Card#
Expir.
TEL #:
Email:
for Credit Cards sign here:
SAMPLE
Type of
Sample Ingredients (REQUIRED)
PRESER-
ANALYSIS REQUESTED:
Con-
101 (BASIC) 110 (PREMIUM)
Sample
IDENTIFICATION
(manure, biosolids, foodscrap,
VATION
tainer
DATE :
GelPak
Solvita
sawdust, wood chips )
use more space on back if
(Plastic,
TIME
List all known ingredients
Dry Ice
Herbicide Bioassay VOA
necessary
Glass,
None
Other _______________________________
Whirl)
RELEASED BY:
DATE:
TIME:
email REPORTS to:
____________________________________ hardcopy requested
RECEIVED BY:
DATE:
TIME:
Cooler Return? [ YES] [ NO ] Note : A blank or a NO means we will discard the container.
A Yes obligates you to absorb the $30 fee for return.
WARNING: This form constitutes a contract for the requested services. A minimum handling fee may be applied if no tests are specified or requested tests are cancelled later. Laboratory
reserves the right too dispose of samples if no information is provided within 72 hours of shipment. Woods End Labs is a USDA-APHIS Inspected and Approved facility.
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