CDOT Form 1439 "Deicer Sample Chain of Custody" - Colorado

What Is CDOT Form 1439?

This is a legal form that was released by the Colorado Department of Transportation - a government authority operating within Colorado. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on October 1, 2017;
  • The latest edition provided by the Colorado Department of Transportation;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of CDOT Form 1439 by clicking the link below or browse more documents and templates provided by the Colorado Department of Transportation.

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Download CDOT Form 1439 "Deicer Sample Chain of Custody" - Colorado

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COLORADO DEPARTMENT OF TRANSPORTATION
DEICER SAMPLE CHAIN OF CUSTODY
Instructions: CDOT personnel collecting field sample are to complete Section 1. Vendor making delivery
to complete Section 2. All persons accepting sample custody complete chain of custody in Section 3.
Print and retain this form with physical sample, send form when testing is complete to CDOT DHM.
Section 1- Sample Collection (Completed by CDOT field personnel)
Sample Collector Name
Region
Section
Patrol
Location Collected
CDOT Tracking Number
4-Digit Patrol #
MMDDYY
Order Number
Carry tracking number to
next page
Product Type
Liquid
Granular
Vendor
Product
Envirotech
Apex
Ice Slicer
Desert Mountain
Ice Ban 305
Rocanville
GMCO
NexGen Torch
Rapid Thaw
Other:
Product Name
Vendor
CDOT
Production Location
Date Produced
Salt Used
Brine
Vendor Bill of Lading #
Lot Number
Date/Time
Date
Time
Sampled
Sample Specific Gravity
Temperature
°F
Field Notes (Optional):
Section 2- Vendor Release (Completed by Vendor and CDOT)
(Vendor) My signature below corroborates the deicer sample taken from the delivery as documented on attached Delivery Order
Form/Bill of Lading was collected by CDOT Maintenance Personnel adhering to the most recent CDOT Standard Operating Guide
(SOG) for Winter M&O (August 2010) and Existing Liquid and Granular editions of the CDOT Standards for Deicing Products
(2017).
Vendor Relinquishing Sample
Date
Time
Name
Signature
CDOT Personnel Accepting Sample
Date
Time
Location
Signature
For Information Only
Sampling Program Contact
Test Facility Contact
CDOT Headquarters - Division of Highway Maintenance
Analytical Laboratories, Inc. (ALI)
15285 S Golden Rd, Building 45
1804 N. 33rd Street
Golden, CO 80401
Boise, ID 83703
(303) 512-5500
(208) 342-5515
http://intranet/maintenance/maintenance-engineering
CDOT Form #1439 10/17
Previous editions are obsolete and may not be used
Page 1
COLORADO DEPARTMENT OF TRANSPORTATION
DEICER SAMPLE CHAIN OF CUSTODY
Instructions: CDOT personnel collecting field sample are to complete Section 1. Vendor making delivery
to complete Section 2. All persons accepting sample custody complete chain of custody in Section 3.
Print and retain this form with physical sample, send form when testing is complete to CDOT DHM.
Section 1- Sample Collection (Completed by CDOT field personnel)
Sample Collector Name
Region
Section
Patrol
Location Collected
CDOT Tracking Number
4-Digit Patrol #
MMDDYY
Order Number
Carry tracking number to
next page
Product Type
Liquid
Granular
Vendor
Product
Envirotech
Apex
Ice Slicer
Desert Mountain
Ice Ban 305
Rocanville
GMCO
NexGen Torch
Rapid Thaw
Other:
Product Name
Vendor
CDOT
Production Location
Date Produced
Salt Used
Brine
Vendor Bill of Lading #
Lot Number
Date/Time
Date
Time
Sampled
Sample Specific Gravity
Temperature
°F
Field Notes (Optional):
Section 2- Vendor Release (Completed by Vendor and CDOT)
(Vendor) My signature below corroborates the deicer sample taken from the delivery as documented on attached Delivery Order
Form/Bill of Lading was collected by CDOT Maintenance Personnel adhering to the most recent CDOT Standard Operating Guide
(SOG) for Winter M&O (August 2010) and Existing Liquid and Granular editions of the CDOT Standards for Deicing Products
(2017).
Vendor Relinquishing Sample
Date
Time
Name
Signature
CDOT Personnel Accepting Sample
Date
Time
Location
Signature
For Information Only
Sampling Program Contact
Test Facility Contact
CDOT Headquarters - Division of Highway Maintenance
Analytical Laboratories, Inc. (ALI)
15285 S Golden Rd, Building 45
1804 N. 33rd Street
Golden, CO 80401
Boise, ID 83703
(303) 512-5500
(208) 342-5515
http://intranet/maintenance/maintenance-engineering
CDOT Form #1439 10/17
Previous editions are obsolete and may not be used
Page 1
Section 3 – Chain of Custody (Completed by all persons who handle sample)
Sample Tracking Number
Product Name
Releasing Sample
Date
Time
Location
Signature
Name
Position
1
Accepting Sample
Date
Time
Location
Signature
Name
Position
Releasing Sample
Date
Time
Location
Signature
Name
Position
2
Accepting Sample
Date
Time
Location
Signature
Name
Position
Releasing Sample
Date
Time
Location
Signature
Name
Position
3
Accepting Sample
Date
Time
Location
Signature
Name
Position
Releasing Sample
Date
Time
Location
Signature
Name
Position
4
Accepting Sample
Date
Time
Location
Signature
Name
Position
Releasing Sample
Date
Time
Location
Signature
Name
Position
5
Accepting Sample
Date
Time
Location
Signature
Name
Position
Releasing Sample
Date
Time
Location
Signature
Name
Position
6
Accepting Sample
Date
Time
Location
Signature
Name
Position
Releasing Sample
Date
Time
Location
Signature
Name
Position
7
Accepting Sample
Date
Time
Location
Signature
Name
Position
Releasing Sample
Date
Time
Location
Signature
Name
Position
8
Accepting Sample
Date
Time
Location
Signature
Name
Position
Releasing Sample
Date
Time
Location
Signature
Name
Position
9
Accepting Sample
Date
Time
Location
Signature
Name
Position
Releasing Sample
Date
Time
Location
Signature
Name
Position
10
Accepting Sample
Date
Time
Location
Signature
Name
Position
Previous editions are obsolete and may not be used
CDOT Form #1439 10/17 Page 2
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