"Chain of Custody Record Template - Sierra Environmental Monitoring, Inc"

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SIERRA ENVIRONMENTAL MONITORING, INC.
CHAIN OF CUSTODY RECORD
NEW ADDRESS ?
P.O. or Project #
1135 FINANCIAL BOULEVARD - RENO - NEVADA - 89502
Results To:
Invoice To:
PHONE: (775) 857 - 2400
FAX: (775) 857 - 2404
E-Mail sem@sem-analytical.com
Results To:
Client Name
Analyses Requested
Turnaround Time/Results/Invoice
Compliance
E-mail
Monitoring
Mailing Address
Yes:
Phone:
Standard:
Fax:
Rush (Surcharge will Apply)
City
State
Zip
Report Attention:
No:
Same Day:
72 Hr:
24 Hr:
4 Day:
48 Hr:
5 Day:
Invoice To:
Client Name
Other (specify):
E-mail
Date Sent:____________________
Mailing Address
Phone #
Send Results Via:
Fax #
City
State
Zip
Invoice Attention:
Mail:
Email:
Fax:
Phone:
Lab Use Only
Sub-Sample
Send Invoice Via:
pH
Sampled by:
Signature:
Mail:
Email:
Fax:
I attest to the validity and authenticity of the sample. I am aware that tampering with or intentionally
mislabeling the sample location, date or time is considered fraud and may be grounds for legal action.
Time
Sample
Preservative*
Remarks
Date Sampled
Sampled
Type*
See Key Below
Sample Identification
<2
>12
Signature
Print Name
Company
Date
Time
Relinquished By:
Received By:
Relinquished By:
Received By:
Relinquished By:
Received By Laboratory:
Samples are discarded 30 days after results are reported unless other arrangements are made. Hazardous samples will be
returned to client or disposed of at client expense. The analytical results associated with this
Custody Seal Intact
COC apply only to thesamples as they are received by the laboratory. The liability of the laboratory is limited to the amount paid for the report.
SEM COC
Terms: Net thirty (30) days on approved credit.
Yes:
No:
None:
Form
Sample Temperature
Revised
* KEY:
Sample Type: 1=Drinking Water, 2=Surface Water, 3=Ground Water, 4=Waste Water, 5=Soil, 6=RCRA, 7=Other
2/22/11
Preservative: 1=NaOH, 2=NaOH + ZnOAC, 3=HNO3, 4=H2SO4, 5=Na2S2O3, 6=None, 7=Other
Degrees C
_________
SIERRA ENVIRONMENTAL MONITORING, INC.
CHAIN OF CUSTODY RECORD
NEW ADDRESS ?
P.O. or Project #
1135 FINANCIAL BOULEVARD - RENO - NEVADA - 89502
Results To:
Invoice To:
PHONE: (775) 857 - 2400
FAX: (775) 857 - 2404
E-Mail sem@sem-analytical.com
Results To:
Client Name
Analyses Requested
Turnaround Time/Results/Invoice
Compliance
E-mail
Monitoring
Mailing Address
Yes:
Phone:
Standard:
Fax:
Rush (Surcharge will Apply)
City
State
Zip
Report Attention:
No:
Same Day:
72 Hr:
24 Hr:
4 Day:
48 Hr:
5 Day:
Invoice To:
Client Name
Other (specify):
E-mail
Date Sent:____________________
Mailing Address
Phone #
Send Results Via:
Fax #
City
State
Zip
Invoice Attention:
Mail:
Email:
Fax:
Phone:
Lab Use Only
Sub-Sample
Send Invoice Via:
pH
Sampled by:
Signature:
Mail:
Email:
Fax:
I attest to the validity and authenticity of the sample. I am aware that tampering with or intentionally
mislabeling the sample location, date or time is considered fraud and may be grounds for legal action.
Time
Sample
Preservative*
Remarks
Date Sampled
Sampled
Type*
See Key Below
Sample Identification
<2
>12
Signature
Print Name
Company
Date
Time
Relinquished By:
Received By:
Relinquished By:
Received By:
Relinquished By:
Received By Laboratory:
Samples are discarded 30 days after results are reported unless other arrangements are made. Hazardous samples will be
returned to client or disposed of at client expense. The analytical results associated with this
Custody Seal Intact
COC apply only to thesamples as they are received by the laboratory. The liability of the laboratory is limited to the amount paid for the report.
SEM COC
Terms: Net thirty (30) days on approved credit.
Yes:
No:
None:
Form
Sample Temperature
Revised
* KEY:
Sample Type: 1=Drinking Water, 2=Surface Water, 3=Ground Water, 4=Waste Water, 5=Soil, 6=RCRA, 7=Other
2/22/11
Preservative: 1=NaOH, 2=NaOH + ZnOAC, 3=HNO3, 4=H2SO4, 5=Na2S2O3, 6=None, 7=Other
Degrees C
_________