|CHAIN OF CUSTODY
Chain of Custody
Getting Samples to Phase
for Completing Phase Separation Sciences
Sample Chain of Custody/Agreement Form
(PDF file - requires Acrobat
Interactive Chain of Custody (editable PDF file)
The Client, by signing, or having the client's agent sign this "Sample Chain of Custody/Agreement Form",
agrees to pay for the above requested services per the latest version of the Service Brochure or PSS-provided
quotation, including any and all attorney's or other reasonable fees if collection becomes necessary.
- CLIENT: Name of Company submitting
OFFICE LOCATION: Please provide location of the office
submitting the samples if your Company has more than one location -
either city or state.
PROJECT MANAGER: Person PSS should contact if additional information is required.
This is also the person the report will be sent to unless specified differently in the
Instructions box in the lower right hand corner of the form
PHONE NO: Phone number PSS should call if questions arise about sample or analysis
EMAIL: Provide the email address of the project manager
FAX NO: Provide number (if applicable) that the report should be faxed to
PROJECT NAME: Provide name of project as it is to appear on the report
SITE LOCATION: Provide the site location (if applicable) as it is to appear on the
PROJECT NUMBER: Provide the project number (if applicable) as you want it to appear
on the report
P.O. NUMBER: Provide purchase order number (if applicable) that should appear on
SAMPLERS: Provide the name(s) of each person who collects the
DW CERT. NUMBER: Provide the Maryland Drinking Water
Certification number for the sampler
- LAB NO.: For laboratory use only
SAMPLE IDENTIFICATION: Identify sample as it should appear on the report
DATE: The date the sample was collected
TIME: The time the sample was collected
MATRIX: The physical nature of the sample (Surface
Water, Oil, Soil,
No. CONTAINERS: Number of containers provided for each sample
SAMPLE TYPE: Specify C for composite sample or
G for grab sample if applicable to
- Preservatives Used: Specify preservative
used for each analysis requested, leave blank if none were used
Analysis Required: Specify the analysis requested for each sample by listing the
analyte (or list of analytes) on the diagonal line. Put an X in the box below the
parameter that corresponds to the sample that requires that analyte.
REMARKS: Additional information about a particular sample, i.e. hold for
further instruction or expect high levels
- Requested Turnaround Time: Indicate
requested turnaround time for sample results. Standard T/A will
apply if not marked.
Sample Condition Upon Receipt and Custody Seal: For laboratory use only
Data Deliverables Required: Specify level of data required with report. A
Certificate of Analysis form (tabular results) is PSSs standard report. Contact lab
for information on Lab Blank Summaries, QC Summaries, and CLP-Like or
Full VCP data packages (please note that a
surcharge usually applies to data packages)
Shipping Carrier: For laboratory use only
Special Instructions: Indicate any other special instructions that are appropriate,
including quote number if applicable.
- Relinquished By: This is
one of the most important parts of this form. The person that has collected the sample
should sign, date and time the form in the top most block (Relinquished By:).
Each person that has accepted the sample should sign in the adjacent Received By:
box. When the sample is relinquished again, it should be signed with time and date in the
next Relinquished By: box.