Chain Of Custody Form - Paradigm
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1179 Lake Avenue, Rochester, NY 14608
Office (585) 647-2530 Fax (585) 647-3311
CHAIN OF CUSTODY
REPORT TO:
INVOICE TO:
CLIENT:
CLIENT:
LAB PROJECT ID
Same
ADDRESS:
ADDRESS:
CITY:
STATE:
ZIP:
CITY:
STATE:
ZIP:
Quotation #:
PHONE:
PHONE:
Email:
ATTN:
ATTN:
PROJECT REFERENCE
Matrix Codes:
AQ - Aqueous Liquid
WA - Water
DW - Drinking Water
SO - Soil
SD - Solid
WP - Wipe
OL - Oil
NQ - Non-Aqueous Liquid
WG - Groundwater
WW - Wastewater
SL - Sludge
PT - Paint
CK - Caulk
AR - Air
REQUESTED ANALYSIS
C
C
N
O
O
U
M
N
M
C
M
G
A
T
P
O
B
PARADIGM LAB
TIME
R
T
A
DATE COLLECTED
O
SAMPLE IDENTIFIER
D
E
REMARKS
SAMPLE
COLLECTED
A
R
I
S
E
R
NUMBER
B
I
N
I
S
X
E
T
O
R
E
F
S
Turnaround Time
Report Supplements
Availability contingent upon lab approval; additional fees may apply.
Total Cost:
Sampled By
Date/Time
Standard 5 day
None Required
None Required
10 day
Batch QC
Basic EDD
Relinquished By
Date/Time
Rush 3 day
Category A
NYSDEC EDD
Received By
Date/Time
P.I.F.
Rush 2 day
Category B
Rush 1 day
Received @ Lab By
Date/Time
Other
Other
Other EDD
See additional page for sample conditions.
By signing this form, client agrees to Paradigm Terms and Conditions (reverse).
please indicate date needed:
please indicate package needed:
please indicate EDD needed :
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