Chain-Of-Custody / Analytical Request Document
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1
2CHAIN-OF-CUSTODY / Analytical Request Document
The Chain-of-Custody is a LEGAL DOCUMENT. All relevant fields must be completed accurately.
®
Page:
of
Section A
Section B
Section C
Required Client Information:
Required Project Information:
Invoice Information:
Company:
Report To:
Attention:
Address:
Copy To:
Company Name:
REGULATORY AGENCY
Address:
NPDES
GROUND WATER
DRINKING WATER
Email To:
Purchase Order No.:
Pace Quote
UST
RCRA
OTHER
Reference:
Phone:
Fax:
Project Name:
Pace Project
Site Location
Manager:
Requested Due Date/TAT:
Project Number:
Pace Profile #:
STATE:
Requested Analysis Filtered (Y/N)
Section D
Matrix Codes
COLLECTED
Preservatives
Required Client Information
MATRIX / CODE
Drinking Water
DW
Water
WT
COMPOSITE
Waste Water
WW
COMPOSITE
START
END/GRAB
Product
P
Soil/Solid
SL
SAMPLE ID
Oil
OL
Wipe
WP
(A-Z, 0-9 / ,-)
Air
AR
Sample IDs MUST BE UNIQUE
Tissue
TS
Other
OT
Pace Project No./ Lab I.D.
DATE
TIME
TIME
DATE
1
2
3
4
5
6
7
8
9
10
11
12
ADDITIONAL COMMENTS
RELINQUISHED BY / AFFILIATION
DATE
TIME
ACCEPTED BY / AFFILIATION
DATE
TIME
SAMPLE CONDITIONS
SAMPLER NAME AND SIGNATURE
PRINT Name of SAMPLER:
DATE Signed
SIGNATURE of SAMPLER:
(MM/DD/YY):
F-ALL-Q-020rev.07, 15-May-2007
*Important Note: By signing this form you are accepting Pace's NET 30 day payment terms and agreeing to late charges of 1.5% per month for any invoices not paid within 30 days.
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