PCB Sample Chain of Custody Form
Project Name:
Project Number:
Location:
Client:
Sampler's Name:
Sampling Date:
Sample Information
Sample ID
Sample Location
Sample Matrix
Sample Type
Container Type
Preservative
Analysis Requested
Date/Time Collected
Relinquished By (Name/Signature)
Date/Time
Received By (Name/Signature)
Date/Time
Comments / Special Instructions
Final Receipt at Laboratory
Received By (Name/Signature):
Date/Time:
Condition of Samples: