Massdep Drinking Water Chain Of Custody
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1MASSDEP DRINKING WATER CHAIN OF CUSTODY
Page
Date Rec'd in Lab:
ALPHA Job #
of
Project Information
Report Information
Data Deliverables
Billing Information
Westborough, MA
Mansfield, MA
Project Name:
FAX
EMAIL
Same as Client Info
TEL: 508-898-9220
TEL: 508-822-9300
PWS Name:
ADEx
PO #
FAX: 508-898-9193
508-822-3288
Add'l Deliverables
Client Information
Project Location:
Please Indicate PWS Class Below
Project PWS ID#
COM
Client:
Project Manager:
NTNC
Address:
ALPHA Quote #:
TNC
Turn-Around Time
Phone:
Standard
Due Date:
Fax:
SUBJECT TO MCL REPORTING
Rush
(only if pre approved)
Time:
Email:
ANALYSIS
Sample Filtration
These samples have been previously analyzed by Alpha
T
Other Project Specific Requirements/ Comments/Detection Limits
Done
o
Lab to do
t
Preservation
a
l
Lab to do
B
(Please Check Below)
o
t
Source(1)
Type
Sample(2)
t
ALPHA Lab ID
DEP
DEP
Collection
Sample
Sampler's
l
(Lab Use Only)
Location Code
Location Name
Matrix
Initials
Date
Time
e
s
Container Code
Preservative Code:
(1) List connected sources if Multiple
Please print clearly, legibly and
P = Plastic
A = None
Container Type
A = Amber Glass
B = HCl
completely. Samples can not be
V = Vial
C = HNO3
logged in and turnaround time
(2) Explain if sample type is Special
G = Glass
D = H2SO4
Preservative
clock will not start until any
B = Bacteria Cup
E = NaOH
ambiguities are resolved. BY
C = Cube
F = MeOH
O = Other
G = NaHSO4
EXECUTING THIS COC, THE
Relinquished By:
Date/Time
Received By:
Date/Time
E = Encore
H = Na2S2O3
CLIENT HAS READ AND
D = BOD Bottle
I = Ascorbic Acid
AGREES TO BE BOUND BY
J = NH4Cl
ALPHA'S TERMS &
K = Zn Acetate
O = Other
CONDITIONS. (See reverse
side.)
Form No: 01-24 HC (rev 18-Sept-2013)
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