Appendix A.4.

Appendix A.4.
- Groundwater Sample Chain-of-Custody

Forms
'1!1
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..
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ChainofCustodyRecord

/
ProjectNumber:
Sampler(Print
Address: Sampler(PrintName):
ShipmentMethod: '"-e.J"
Alrbill Number: _
Phone: Laboratory Receiving:
Fax:
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{ Time:
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Total #ContainersReceived?
Level I 0 Routine 0 COCSeals Present?
level II 0 24Hour o
COOSealsIntact?
level Ill 0 1Weok 0
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Other 0 Olhor__
Temperature?
REC'D JUL.15
2013
13- 07098
Eberlin&Services
ro1Scad>oroRoad !Iii EBERLINE
oakRidge.TN31830 . SE.RVICE.S
(865) 481-0083 Phone (865) 493-4621 Fax
'(j) Pag._l_ot.l_

,4m3
Purchase
Ordertt:________
'\,
. ----------..------,----------"'"'
REC'D JUL152.013 13- 07091
EberllneServlclts
601 Sc:alboloRoad
ChainofCustodyRecord

1604
oakRidge,TN37830 IE:B E R L IN E
SEI'IYICES
?
-
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1b4'0 Level II 0 24Hour 0
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level Ill 0 1Week 0
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..

REC'D JUL .15 2013 13- 0 7 1 0 0
Eberllne Servl<:es (
Chain of Custody Record

aot Scartlolo Road IE B E R L I N E
1604 oak Ridge, lN 37830 S E FlY ICES
(865) 4810683 Phone (865)483-4621 Fax
Project Number:
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Sampler (Print ... (j) Paga_Lor..l_
Address: Sampler (Print Name): J
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Shipment Method:
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Fax:
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1 Week 0
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Other 0 Other_
Temperature?
--0 . _________ ,__ ,_________
REC'D JUL15 3- 0 7 1 0 0
1
Eblrllne Services
601 Sc:albolo Road

1604 oak Ridge, TN 37830
1:. SERVICES
(865) 481.Q683 Phone (865) 493-4621 Fax
Project Number:
ltf
Sampler (Print -- '(D Paga..orL
Address: Sampler (Print Name): ra
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Shipment Method:
Airbill Number: _
Fax:
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Date: Time:
Sample Custodian Remarks (Completed By Laboratory):
QAJQCLevel I Turnaround I Sample Receipt
Total # Containers Received?
Level I 0 RouUne 0 COC Saals Present?
Level II 0 24Hour 0
COC Seals Intact?
Level Ill
Relinquished by: (Signature) I O 0 1 Week 0
Other 0
Other __
Temperatura?
,...
I
REC'D JUL 15 2013
Ebertlne S.rvlcl
601 Scarbolo Ro
N
EAVICli!:S
(865)481.()683 Phone (865) 483-4821 Fax
-
Project Name:(J..J:i:::f'f-

Project Number:
,!Jf
Send Report To:f-Av{
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Heceivea (::>lgnature) oate: lime:
1 (\tl\ 1 r(f"{r,
Level I 0 Routine 0 COC Seals Present?
Level II 0 24 Hour 0 COC Seals Intact?
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REC'D J U L.15 2013
1.
EbefllneService
601 ScatboloRo

1604 Oak Ridge, TN37830 .. !h:RYICI!:S
(BSS) 481.()683 Phone(BSS) 483-4621 Fax
ie/
I -
Project Name:().tL:::f{-

ProjectNumber:

Send Report
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Airbill Number:
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Phone: laboratoryReceiving: Ordortt__

Fax:
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Date lime Matrix Containers Instructions,etc. (tobecompletedbylab)
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1 (\fk1 I(I '-( r,
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Level II 0 24Hour 0 COCSealsIntact?
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::=REC'DJULlP ..3 13-07111

. SERVICES )481.()683Phone.(865)483-4621 Fax E a E R L IN E
1604
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ProjectNumber: Project Name:(J,'J1::Jt tA, f
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Love! Ill 0 1Week Cl
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Temperatura?
- ------
0
''i 46EC'D JUL 22 2013 ,
EberllntServlca
601 Sc:alboiO Road
13- ]

1604 oakRldgo, TN3?830
(865)481.Q683Phone (8651483-4821 Fax
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ProjectNumber:
ProjectName:f1
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-- -
13-07147
REC'D JUL 22 2013
Ebertlne SeMen
601 SCalbolo Road
N
1604 oak Rldgo, TN 3'1830
(865)481-tl683 Phone (665)483-4621 FIUI
Project Name:(j

Project Number:
Send Report l. -- Sampler (Print Name):
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13-07154 REC'D JUL 222013
EberllntServlcu
601 ScamoroRoad

1604 oakRidgo,TN37830

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13-07170
Ebertlne SeMc:ea
601 S<:eltloro Road

SCI'IVICES
(865) 48Hl683 F'ttone (865} 483-4621 Fax
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Page 5 of 26 8/7/2013

Appendix A.4. - Groundwater Sample Chain-of-Custody Forms

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Appendix A.4. - Groundwater Sample Chain-of-Custody Forms

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