Containers

Chain of Custody

Getting Samples to Phase

Service Brochure

Environmental Sampling Guide

Compound Lists

Instructions for Completing Phase Separation Science’s
Sample Chain of Custody/Agreement Form
(PDF file - requires Acrobat Reader)

Interactive Chain of Custody (editable PDF file)

1. CLIENT: Name of Company submitting samples
   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 Special 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 report
   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 invoice
   SAMPLERS: Provide the name(s) of each person who collects the samples
   DW CERT. NUMBER: Provide the Maryland Drinking Water Certification number for the sampler
   
   
2. 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, Drinking Water, Ground Water, Waste Water, Oil, Soil, Waste Liquid, Waste Solid, Wipe)
   No. CONTAINERS: Number of containers provided for each sample
   SAMPLE TYPE: Specify C for composite sample or G for grab sample if applicable to project
   
   
3. 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”
   
   
4. 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 PSS’s 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.
   
   
5. 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.