Legionella Chain Of Custody
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1SanAir ID Number
1551 Oakbridge Drive, Suite B
Legionella
Powhatan, VA 23139
Chain of Custody
804.897.1177 / 888.895.1177
Fax 804.897.0070
Form #69, Revision 1, 1/28/2016
Company:
Project Number:
Phone #:
Address:
Project Name:
Phone #:
City, State, Zip:
Date Collected:
Fax #:
Account #:
P.O. Number:
Email:
Samples Collected By:
Email:
Sample
Biocides
Sample
Sample
Sampling
Sample #
Sample Site
Water System**
Type*
Present?
Volume
Temp.
Time
W / SL / SW
CT / CL / OL / PR / E / S / T / F
Yes / No
W / SL / SW
CT / CL / OL / PR / E / S / T / F
Yes / No
W / SL / SW
CT / CL / OL / PR / E / S / T / F
Yes / No
W / SL / SW
CT / CL / OL / PR / E / S / T / F
Yes / No
W / SL / SW
CT / CL / OL / PR / E / S / T / F
Yes / No
W / SL / SW
CT / CL / OL / PR / E / S / T / F
Yes / No
W / SL / SW
CT / CL / OL / PR / E / S / T / F
Yes / No
W / SL / SW
CT / CL / OL / PR / E / S / T / F
Yes / No
W / SL / SW
CT / CL / OL / PR / E / S / T / F
Yes / No
W / SL / SW
CT / CL / OL / PR / E / S / T / F
Yes / No
W / SL / SW
CT / CL / OL / PR / E / S / T / F
Yes / No
*Sample Type: W = Water, SL = Slime, SW = Swab
**Water System: CT = Cooling Tower, CL = Closed Loop, OL = Open Loop, PR = Process Water
EW = Equipment Water, S = Sink, T = Tub, F = Fountain
If biocides are present, please list names: _________________________________________ Inactivating Agent Used: Yes / No
Samples Relinquished by:____________________________
Date: _______________ Shipment Time: ____________
Page ____ of ____
For Office Use Only
Samples Received by: _____________________________
Date: __________________ Receiving Time: ____________
□
□
Sample Temp. At Receipt: ___________ Samples Were Subjected To ISO/OSHA Criteria and Were
Accepted
Rejected (Tech. Initials:_______)
op___________)
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