FORM 4
EP 11101-30
EXAMPLE CHAIN OF CUSTODY FORM
31 Aug 01
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:
1.1.1.2
Signature
1.1.1.3
Signature
1.1.1.1
Signature
Printed Name
Printed Name
Printed Name/Certification Number
Company Name
Company Name
Company Name
Date/Time
Date/Time
Date/Time
Figure B-4: Example Chain of Custody Form
B-11
Previous Page
