Mold Testing Services, LLC, 2900 S,. Phillips Ave.

, Suite 700m Sioux Falls, SD 57105

Ph. 605-951-4857

E-mail: moldymike@moldtestingsd.com

CHAIN OF CUSTODY (COC) FORM FOR MOLD (TAPE/BULK OR AIRBORNE)

Contact Information - Billing

MTS Project No.

Type Client (circle or describe) Homeowner, Realtor, Clean Firm, Business:

Contact Name
Phone/Fax
E-mail

Billing Name/Business

Address
City/State/Zip

Project Information - Sampling Site

Site Name: Homeowner, Business etc - (descibe):
Site Address &Town:
Weather (circle): windy, calm
sunny, ptly cldy, cloudy
air temp
humidity
Sampling Site (circle or describe) - basement, main floor, other:
Reason for Test (circle or describe): health, water damage, visible mold, other:
Sample Date
Sampler
Analysis Requested (circle one) : Visible Mold, Airborne Mold.
Type Cassettes: Allergenco, Air-O-Cell etc

Sample Description

Pump Calibrated? - Yes/No

(Type - T = tape or bulk, A = airborne) ID is field ID - #1 etc. Cassette ID is printed number on side of cassette

Type Test: T = Tape, B = Bulk, A = Airborne. If airborne, note type cassette, sample time & pump air flow rate. Flow rate usually 15 liter/min x 5 minute

ID#

Submitted By
Submitted By

Cassette ID

TypeTest

Description - air - main floor NE room, tape - dark spot E wall, etc

Date
Date

Received By
Received By

Type Cassette

Date
Date

Flow (l/min)

Time (min)

Comments (MTS form 7-19-10):