Groundwater Sampling Chain-of-Custody Form
Project Information
Project Name
Project Number
Date
Site Name
Location
Sampler Information
Sampler Name
Organization
Telephone
Sample Information
Sample ID
Date/Time
Sampling Point
Sample Matrix
Analysis Requested
Preservative Used
Remarks
Chain-of-Custody Record
Date/Time Released
Released By (Name/Signature)
Date/Time Received
Received By (Name/Signature)
Purpose/Comments
Remarks / Additional Information