PT.

Organo Science Laboratory

Plaza Amsterdam Blok A No. 7 Sentul City, Bogor
Tel: 02187962710 Fax: 02187962711 E-mail: info@organolabs.com
CHAIN OF CUSTODY (COC)
COC no: 23-1076 Customer Ref. No:
CUSTOMER AND SAMPLE INFORMATION
Company/Name PT Teknofluida Indonesia Requested Testing and Method by Customer
Taman Tekno BSD City, Sektor XI Jl. Tekno Raya Blok H2
Address
No.3A, RT.18/RW.5, Setu, Kec. Setu, Kota Tangerang Selatan, Banten
Contact Person Mr. Dadang Sobarna Putra

Total Organic Carbon

Phone +62 896 3685 0510 / 021 75876582
e-mail dadang.putra@teknofluida.id

Oil and Grease

Send Report Via Hardcopy e-mail: dadang.putra@teknofluida.id
TAT Requested Normal Rush (5 working day)
Due Date 04-08-2023
Date/Time Collected
Internal Lab. ID * Customer ID Matrix
Date (d-m-y) Time
15:20 Waste
Outlet WWTP 20-07-2023
(WIT) Water
X X

Sample Container: 1000 mL Amber Glass Bottle (1 pc), 200 mL Amber Glass Bottle (1 pc)
Note: Mengggunakan wadah sampel dari organo
Remain Sample: Will be return Will be discard
Special Instruction/Request From Customer:-
1. Suitability between information received (WO/documents/labeling): No discrepancy, there is nothing that needs to be confirmed to Customer
There is a discrepancy, describe it and confirm to customer!:
2. Conformity with method requirements (tick the boxes and/or describe it): According to requirements
Not in accordance with requirements, mention it!:
3. Sample Condition Upon Reception (tick the boxes and/or describe it): Good (no damage, according to the documents such as WO)
Not in good condition, mention it!:
4. Hazard Category: Non hazardous material Hazardous materials, description: Waste Water Samples
Requisition Review/Comment by Laboratory: Laboratory is able to work on this order fully Other:

Terms and Condition upon Sample Reception: This COC made for one Laboratory Analysis Report (LAR). Please confirmed this COC. Sample testing start and
Turn Around Time start to count after you confirm this COC. If you have other desired conditions please let us know.
Confirmed by: Received by Lab: Checked/Approved by Lab:
Company: PT. TFI Company: PT. OSL Company: PT. OSL
Name: Dadang sobarna Putra Name: Mr. Ihsan Kamil Name: Mr. Yadi Bachtiar
Date&Time: 31-07-2023 Date&Time: 31-07-2023 (11:50 WIB) Date&Time: 31-07-2023 (11:50 WIB)
Sign: Sign: Sign:
* Internal lab ID is added when the form has been signed by Customer
FORM7.4-2V04 | Chain of Custody (COC)