Chain Of Custody Record
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3Calgary: 4000 19th St. NE, T2E 6P8. Toll Free (800) 386-7247
CHAIN OF CUSTODY RECORD
of
Edmonton: 9331-48 St. T6B 2R4. Toll Free (800) 386-7247
Page
maxxam.ca
Invoice Information
Report Information (if differs from invoice)
Project Information
Turnaround Time (TAT) Required
5 - 7 Days Regular (Most analyses)
Company :
Company:
Quotation #:
PLEASE PROVIDE ADVANCE NOTICE FOR RUSH PROJECTS
Contact Name:
Contact Name:
P.O. #/ AFE#:
Rush TAT (Surcharges will be applied)
Address:
Address:
Same Day
2 Days
Project #:
1 Day
3-4 Days
Phone:
Phone:
Site Location:
Date Required:
Email:
Email:
Site #:
Rush Confirmation #:
Copies:
Copies:
Sampled By:
Laboratory Use Only
Analysis Requested
Regulatory Criteria
YES NO
Cooler ID
Depot Reception
AT1/CCME
Seal Present
Seal Intact
Temp
Cooling Media
Drinking Water
YES NO
Cooler ID
Saskatchewan
Seal Present
Seal Intact
Temp
D50 (Drilling Waste)
Cooling Media
YES NO
Cooler ID
Other:
Seal Present
Seal Intact
Temp
Cooling Media
Time
Date Sampled
Sample Identification
Sampled
Depth (Unit)
Matrix
Special Instructions
(YYYY/MM/DD)
(HH:MM)
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2
3
4
5
6
7
8
9
10
Please indicate Filtered, Preserved or Both (F, P, F/P)
Relinquished by: (Signature/ Print)
DATE (YYYY/MM/DD)
Time (HH:MM)
Received by: (Signature/ Print)
DATE (YYYY/MM/DD) Time (HH:MM)
Maxxam Job #
AB FCD-00331/6
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