CHAIN OF CUSTODY RECORD

and Authorization for Analysis

Billing Information
Name Company Address City, State, Zip
Standard Turn Around Time is end of day, 10 Work Days after lab receipt. Surcharges may apply for Express Service.

Phone
Quote No. Job No. PO No.

Site Address:

Fax Email Telephone Results Fax Results Email Results

Matrix Codes
AR DW FT GW OL PC PR SL SD SW SB TP WP WW Air Drinking Water Filter Ground Water Oil Paint Chips Product Sludge Solid/Soil Surface Water Swab Tape Wipe Waste Water Comp/ Matrix Grab

Sample State of Origin CT NY NJ PA MA MD Other_____

Sample Receipt Temperature_________C

Container Type / Preservative

Plastic/Glass / Sodium Thiosulfate Plastic / Zinc Acetate + NAOH Plastic / NaOH+Ascorbic Acid

Analysis Requested

Plastic / No Preservatives

Glass / No Preservative

Number of Containers

Time Required:
ELS Use Only Date

DEC Pin #_________________

Sampling Location/Sample ID

Time

Relinquished by: Relinquished by: Relinquished by: Sampler Signature

Date Date Date Date

Time Time Time Time

Received by: Received by: Received at Lab by:

VOA / HCL

DEC Spill #________________

Other: (specify)
Date Date Date

Plastic / HNO3

Glass / H2SO4

Plastic H2SO4

Same Day 1 Work Day 2 Work Days 3 Work Days 4 Work Days 5 Work Days Normal Other:

Remarks/Special Instructions:

Time Time Time