EP 1110-1-31
31 Aug 01
FORM 7
EXAMPLE CHAIN OF CUSTODY FORM
FOR LEAD RISK ASSESSMENT SAMPLING
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 B-8: Example Chain of Custody Form for Lead Risk Assessment Sampling
B-14
Previous Page
