FORM 4
EP 1110-1-29
CHAIN OF CUSTODY FORM
31 Aug 01
FOR LEAD CLEARANCE INSPECTION
Page
of
Project Name
Project Number
Sample Preparation/Analysis Required (check the appropriate box)
Installation
Project Manager
Company Name
Company Address
Phone
Sample ID
Sample Date
Time
Sample Matrix
Laboratory ID
(wipe, paint chip,
soil, other)
Sampler:
1.
Released by:
2.
Received by:
Special Instructions/Comments:
Signature
Signature
Signature
Printed Name/Certification Number
Printed Name
Printed Name
Company Name
Company Name
Company Name
Date/Time
Date/Time
Date/Time
Figure C-4: Chain of Custody Form For Lead Hazard Clearance Inspection
C-5
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