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Appendix E: Chain of Custody Form

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Chain of custody form
Sheet of

This column for lab use only

From:

Date:

To:

Container size, type, preservative and analysis

Container identification

Job code:

Insert your office address here

Size

              

Type*

              

Ph:

Fax:

Preservative code

              

Due date:

Project no:

Sampler(s):

Analytes

              

Project manager:

Signature(s):

Agreement no:

Checked:

Custody seal intact?

Released by:

Received for laboratory by:

Yes

No

Sample cold?

Date:

Time:

Date:

Time:

Yes

No

Lab identification

Date

Time

Matrix

Sample number

Comments

Total no

Tick required analytes

                           
                           
                           
                           
                           
                           
                           
                           
                           
                           
                           
                           

Remarks:

Total

               

Courier job no:

* Container type and preservative codes: P = neutral plastic; N = nitric acid preserved; C = sodium hydroxide preserved; J = solvent washed acid rinsed jar; S = solvent washed acid rinsed glass bottle; VC = hydrochloric acid preserved vial; VS = sulphuric acid preserved vial; BS = sulphuric acid preserved glass bottle; Z = zinc acetate preserved bottle; E = EDTA preserved bottles; ST = sterile bottle

Specify turnaround time:

Note: Samples may contain dangerous and hazardous substances

 

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