Drinking Water Lead Sampling Chain of Custody Record
Facility Name:
Address:
City:
State:
Zip:
Contact Person:
Phone:
Project Name/ID:
Sampler's Name:
Sampling Date:
Sample Information
| Sample ID |
Location/Description |
Collection Date |
Collection Time |
Total Volume (mL) |
Field Notes |
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Chain of Custody
| Date/Time Released |
Released By (Print & Sign) |
Date/Time Received |
Received By (Print & Sign) |
Purpose |
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Laboratory Name/Firm:
Lab Contact:
Phone:
Laboratory Address:
Analysis Requested:
Date/Time Analysis Received: