Sample Chain of Custody Form
This form is used to assure Chain of Custody during transfer of samples from a client to ALS
Minerals, based on the number of items shipped.
(Enter number of items)
Super Sacks
_____________________________
Zip-tied Rice Bags
_____________________________
Bins – Locked/Covered/Uncovered
_____________________________
Color identification: number, letter, etc.
_____________________________
Pallets
_____________________________
Paperwork Included ( please specify): SSF/Client COC, etc.
_____________________________
Other: Boxes/Bags
_____________________________
_____________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________
________________________________________________________________
___________________________________________________________
___________________________
____________________________________________________________________
_____________________________________
Date & Time: ____________________
(Please Print)
Signature:
Client
___________________________________________________
:
_____________________________________(Please Print)
__________________________________________ Date & Time: _____________________
*All shipments received are subject to inspection upon layout; all services are rendered in accordance with
ALS Minerals Terms & Conditions (see the current Schedule of Services & Fees).
Chain of Custody, Version 3.0
11/30/2012