Form Csm-132a - Chain Of Custody Record/ Analysis Form
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1
2SRC Environmental Analytical Laboratories
CHAIN OF CUSTODY /ANALYSIS FORM
Page #__ of ___
102-422 Downey Rd, Saskatoon, SK S7N 4N1
Ph. (306)933-6932, Toll free 800-240-8808
Lab Use Only:
Turnaround Time: Regular
Priority Rush (100% surcharge)
background
Radioactivity:
SRC Group #
Rush (75% surcharge)
0.05-0.2mR/hr
Call Lab if Priority Rush is required
Client Code
>0.2mR/hr
Invoice to:
Date/Time received
Serm Flag
Company Name:
Storage
Contact Name:
Address: _______________________________________________________
# of bottles
City/ Prov:
Preservatives
Postal Code:
Phone:
Size
Email:
In Subgroup #
PO#
Quote #:
Received by: ____________________________
Report Format:
Report Results to:
Ministry of Environment WaterTrax Database
PDF Excel
Analysis Required
Report to: Same as Invoice to?
Special Instructions/Notes:
Company Name: _______________________________
Contact Name: ________________________________
Address: _____________________________________
City/Prov: ____________________________________
Postal Code: __________________________________
Phone: _______________________________________
Email: _______________________________________
Email: _______________________________________
Email: _______________________________________
# of Bottles
Sample Type
Date/Time
Sample Site Description
per site
(water, soil, etc.)
Sampled
I ____________________ hereby relinquish the above listed samples to SRC Analytical and authorize the above listed analysis as per the Standard
(Printed Name)
Terms and Conditions on the ___ day of _____________, _________. Relinquished by Signature: ________________________________
(
Day)
(Month)
(Year)
Form CSM-132A, revised June 3, 2016
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