Chain Of Custody Form

 

 

Chain   o f   C ustody   F orm  

Sample   N umber:_______________  

Important!     A ll   r equested   i nformation   m ust   b e   f illed   o ut   f or   t he   w aste   t o   b e   a ccepted   a nd   p rocessed    

Generator   I nformation:    

Generator   C ompany    

Name:________________________________________________________________    

Mail   A ddress:__________________________________________________________  

  S ite   A ddress:__________________________________________________________    

Contact:________________________________Phone   N umber:___________________    

EPA   I D   N umber:________________________________________________________    

Broker   I nformation:  

Broker   N ame:__________________________________________________________  

Address:______________________________________________________________  

Contact:________________________________Phone   N umber:___________________    

Sample   I nformation:    

Note:     A   g rab   s ample   i s   t o   b e   c ollected   i n   a ll   c ases   w here   o rganic   c ompound   a nalysis   i s   t o   b e   c onducted.     A   c omposite   s ample  

should   b e   r epresentative   o f   t he   w aste   o r   b iased   t oward   t he   w orst   p ossible   c ase.    

Waste   D escription:______________________________________________________    

Waste   C odes:___________________________Quantity   t o   b e   S hipped:____________    

Sampling   M ethod:       _ ___   G rab:  

_ ___Composite:  

 

( Required   f or   O rganic   A nalysis)    

( Required   f or   I norganic   A nalysis

a nd  

   

)

Treatability   S tudy

Sampler   N ame/Signature:_________________________________Date/Time:_________________  

Relinquished   T o   N ame:___________________________________Date/Time:   _ _______________    

Send   s ample   t o:     M ax   E nvironmental   T echnologies,   I nc.     P hone:   7 24-­‐722-­‐3500   2 33   M ax   L ane   /   Y ukon,  

PA   1 5698     F ax:   7 24-­‐722-­‐3520         A TTN:   J effery   F unk         E -­‐mail:  

d

 

ANALYSIS   N EEDED:   ( check   a ll   n eeded)                                                                                   R EPORT   T O:                                 T AT:        

Form   U   A nalysis________________________________________________________________  

XRF   M etals   _ __________________________________________________________________        

 

TCLP   M etals   o n   R aw   S ample   _ ____________________________________________________      

Treatability   S tudy   _ _____________________________________________________________  

Other   _ ______________________________________________________________________