Drinking Water-Bacteriological Chain Of Custody
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MASSDEP DRINKING WATER-BACTERIOLOGICAL
Date Rec'd
ALPHA Job
#
in Lab
CHAIN OF CUSTODY
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
FAX: 508-822-3288
508-822-3288
Add'l Deliverables
PO #
Client Information
Project Location:
Please Indicate PWS Class Below
Client:
Project PWS ID#
COM
Address:
Project Manager:
NTNC
ALPHA Quote #:
TNC
Phone:
Turn-Around Time
Fax:
Standard
Due Date:
SUBJECT TO MCL REPORTING
Rush
(only if pre approved)
Email:
Time:
T
ANALYSIS
Sample Filtration
These samples have been previously analyzed by Alpha
o
Other Project Specific Requirements/ Comments/Detection Limits
Done
t
a
Lab to do
l
Preservation
Lab to do
B
Sample Type, DEP Location Code and Location Name must correspond to the sample information on your MassDEP
o
(Please Specify below)
Coliform Sampling Plan.
t
t
ALPHA Lab ID
Sample
DEP
DEP
Collection
Sample
Sampler's
l
(Lab Use Only)
Type (1)
Location
Location Name
Matrix
Initials
Date
Time
e
Code
Chlorine Result (mg/L)
s
Container Code
Preservative Code:
(1) Sample Type:
Please print clearly, legibly and
P = Plastic
A = None
RS - Routine Distribution Sample
AR - Additional Repeat
Container Type
A = Amber Glass
B = HCl
RO - Original Site Repeat
RW - Raw Water
completely. Samples can not
V = Vial
C = HNO
UR - Upstream Repeat
PT - Plant Tap
3
be logged in and turnaround
G = Glass
DR - Downstream Repeat
SS - Special Sample
D = H
SO
2
4
Preservative
time clock will not start until
B = Bacteria Cup
E = NaOH
any ambiguities are resolved.
C = Cube
F = MeOH
O = Other
BY EXECUTING THIS COC,
G = NaHSO
Relinquished By:
Date/Time
Received By:
Date/Time
4
E = Encore
H = Na
S
O
THE CLIENT HAS READ AND
2
2
3
D = BOD Bottle
I = Ascorbic Acid
AGREES TO BE BOUND BY
J = NH
Cl
4
ALPHA'S TERMS &
K = Zn Acetate
CONDITIONS. (See reverse
O = Other
side.)
Form No: 01-24-Micro HC (rev 18-Sept-2013)
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