Chain Of Custody Record Form
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Chain of Custody Record
TAT(Check One):
Standard
24hr
48hr
72hr
Other____
(Additional charges may apply for rush TAT. If not specified, standard TAT will apply)
1037F MacArthur Road, Reading, PA 19605
Order ID:_______________
610-375-TEST - Fax: 610-375-4090 -
Client Name: ____________________________________________________
Project Name: ____________________________________________
Address: _______________________________________________________ Phone: ________________________
Address: ________________________________________________
_______________________________________________________ Fax: __________________________
________________________________________________
Contact Name: __________________________________________________
Email: _________________________
Payment / P.O. Info: _______________________________________
Comments:
See Codes Below
Comments / Field
Sample Description / Site ID:
Test(s) Requested:
Data:
Relinquished By:
Date:
Sample Conditions
Matrix Key
Bottle Type Key
Reporting Options
NPW = Non-Potable Water
Submitted with COC?
Y / N
P = Plastic
[ ] SDWA Reporting
Time:
G = Glass
Solid = Raw Sludge, Dewatered sludge, soil, etc.
O = Other
PWSID: _____________________
(reported as mg/kg)
Received By:
Date:
Number of containers
Temp ºC: _____
match number on COC?
Y / N
PW = Potable Water (not for SDWA compliance)
Preservative Key
[ ] Fax
Time:
Acceptable: Y / N
SDWA = Safe Drinking Water Act Potable Sample
N = Sodium
[ ] Email
All containers in tact?
Y / N
Thiosulfate
Relinquished By:
Date:
Sample Type Key
SDWA Sample Types
A = Ascorbic Acid
[ ] Other_____________________
Temp ºC: _____
H = HNO
G = Grab
D=Distribution
3
Time:
Tests within holding
C = HCl
[ ] Return a copy of this form with
Acceptable: Y / N
E=Entry Point
times
Y / N
S = H
SO
Report
8HC = 8 Hr.
R=Raw
2
4
Received in Lab By:
Date:
OH = NaOH
Composite
C=Check
Temp ºC: _____
O = Other
S=Special
40 mL VOA vials free of
NA = None
Time:
24HC = 24 Hr.
M=Maximum
Acceptable: Y / N
headspace?
Y / N
Required
Composite
Residence
Signing this form indicates your agreement with SWTL’s Standard Terms and Conditions unless otherwise specified in writing. SLF059 Rev. 1.4 Effective November 12, 2014
Shaded areas are for SWTL use only.
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Parent category: Legal