Chain-Of-Custody Record
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1Chain of Custody Record
5560 Corporate Exchange Court SE
COC No.
Grand Rapids, MI 49512
For Lab Use Only
Phone (616) 975-4500
Fax (616) 942-7463
Pg.
of
Analyses Requested
Cart
PRESERVATIVES
VOA Rack/Tray
Client Name
Project Name
A
NONE pH~7
B
HNO
pH<2
3
Receipt Log No.
Address
Client Project No. / P.O. No.
C
H
SO
pH<2
2
4
D
1+1 HCl pH<2
Project Chemist
City, State Zip
Invoice To
Client
E
NaOH pH>12
Other (comments)
F
ZnAc/NaOH pH>9
Work Order No.
Phone
Contact/Report To
G
MeOH
Container Type (corresponds to Container Packing List)
H
Other (note below)
C
G
Sample
Sample
Matrix
O
R
Field Sample ID
Cooler ID
Sample Date
Sample Comments
Schedule
Matrix
Total
M
A
Code
Number
Time
Number of Containers Submitted
P
B
1
2
3
4
5
6
7
8
9
10
Sampled By (print)
Comments
How Shipped?
Hand ____
Carrier_______________
Sampler's Signature
Tracking No.
1. Relinquished By
Date
Time
2. Relinquished By
Date
Time
3. Relinquished By
Date
Time
Company
1. Received By
Date
Time
2. Received By
Date
Time
3. Received For Lab By
Date
Time
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