Chain-Of-Custody Form - Laboratory Services Agreement
Download a blank fillable Chain-Of-Custody Form - Laboratory Services Agreement in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Chain-Of-Custody Form - Laboratory Services Agreement with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1180A Market Place Blvd.
Chain-of-Custody Form
Lab #
Knoxville, TN 37922
(865) 330-0037
siremlab com
Project Name
Project #
Analysis
Preservative
Project Manager
Email
Preservative Key
Company
0. None
1. HCL
Address
2. Other
3. Other
4. Other
Phone #
5. Other
6. Other
Sampler's
Sampler's Printed
Signature
Name
Sampling
# of
Client Sample ID
Lab ID
Matrix
Other Information
Containers
Date
Time
Sample Receipt
Invoice Information
For Lab Use Only
Cooler Condition:
P.O. #
Cooler Temperature:
Bill To:
Custody Seals:
Yes
No
Relinquished By:
Received By:
Relinquished By:
Received By:
Relinquished By:
Received By:
Signature
Signature
Signature
Signature
Signature
Signature
Printed
Printed
Printed
Printed
Printed
Printed
Name
Name
Name
Name
Name
Name
Firm
Firm
Firm
Firm
Firm
Firm
Date/Time
Date/Time
Date/Time
Date/Time
Date/Time
Date/Time
Distribution: White - Return to Originator: Yellow - Lab Copy: Pink - Retained by Client
In the absence of an executed agreement, submission of samples to SiREM implies consent for performance of analyses specified on this Chain-of-Custody form and agreement
with the terms and conditions of the SiREM Laboratory Services Agreement. The entity submitting samples shall be responsible for payment in full for said analyses.
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business